Criteria

Clinical Notes

Informed Consent

Informed
consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient
has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during
treatment plan discussion)

Subjective

Verify Patient

          Name:

          DOB:

Minor:

Accompanied
by:

Demographic:

Gender Identifier Note:

CC:

HPI:

Pertinent history in record and from patient: X

During assessment: Patient describes their mood as X and
indicated it has gotten worse in TIME.

Patient self-esteem appears fair, no reported feelings of excessive guilt,

no reported anhedonia, does not report sleep disturbance,  does not report change in appetite,  does not report libido disturbances, does not report change in
energy,

no reported changes in
concentration or memory.

Patient does not report increased activity, agitation,
risk-taking behaviors, pressured speech, or euphoria.  Patient does not report excessive
fears, worries or panic attacks.

Patient does not report hallucinations, delusions,
obsessions or compulsions.  Patient’s activity level, attention
and concentration were observed to be within normal limits.  Patient does not report symptoms of eating disorder. There is no recent weight loss or
gain. Patient does not report symptoms of a characterological nature.

SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent
behavior, denies
inappropriate/illegal behaviors.

Allergies:
NKDFA.

(medication & food)

Past Medical Hx:

Medical
history: Denies
cardiac, respiratory, endocrine and neurological issues, including history
head injury.

Patient
denies history of
chronic infection, including MRSA, TB, HIV and Hep C.

Surgical history no surgical history reported

Past Psychiatric Hx:

Previous
psychiatric diagnoses: none reported.

Describes
stable course of illness.

Previous medication trials:
none reported.

Safety
concerns:

History of Violence to Self:  none reported

History of Violence to Others: none
reported    

Auditory
Hallucinations:

Visual
Hallucinations:

Mental
health treatment history
discussed:

History of outpatient treatment: not reported

Previous psychiatric hospitalizations: not reported

Prior substance
abuse treatment: not
reported

Trauma history:
Client does not
report history of trauma including abuse, domestic violence, witnessing
disturbing events.

Substance Use:
Client denies use or
dependence on nicotine/tobacco products.

Client
does not report abuse
of or dependence on ETOH, and other illicit drugs.

Current
Medications: No current medications.

           (Contraceptives):

             Supplements:

Past Psych Med Trials:

Family Medical Hx:

Family Psychiatric Hx:

          Substance
use

          Suicides

         
Psychiatric diagnoses/hospitalization

         
Developmental diagnoses

Social
History:

Occupational
History: currently unemployed.
Denies previous occupational hx

Military
service History: Denies previous military hx.

Education
history:  completed
HS and vocational certificate

Developmental
History: no significant details reported.

            (Childhood History include in
utero if available)

Legal
History: no reported/known legal issues, no reported/known conservator or guardian.

Spiritual/Cultural
Considerations: none
reported.

ROS:

Constitutional:  No report of fever or weight loss. 

Eyes:  No report of acute vision changes or eye pain. 

ENT:  No report of hearing changes or difficulty swallowing. 

Cardiac:  No report of chest pain, edema or orthopnea.  

Respiratory:  Denies dyspnea, cough or wheeze. 

GI:  No report of abdominal pain. 

GU:  No report of dysuria or hematuria. 

Musculoskeletal:  No report of joint pain or swelling. 

Skin:  No report of rash, lesion, abrasions. 

Neurologic:  No report of seizures, blackout, numbness or focal weakness.  Endocrine: 
No report of
polyuria or polydipsia. 

Hematologic:  No report of blood clots or easy bleeding. 

Allergy:  No report of hives or allergic reaction.

Reproductive: No report of significant issues. (females: GYN hx;
abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)

Verify Patient: Name, Assigned identification number
(e.g., medical record number), Date of birth, Phone number, Social security
number, Address, Photo.

Include demographics, chief complaint,
subjective information from the patient, names and relations of others
present in the interview.

HPI:

, Past Medical and Psychiatric History,

Current Medications, Previous Psych Med
trials,

Allergies.

 Social History, Family History.

Review of Systems (ROS) – if ROS is
negative, “ROS noncontributory,” or “ROS negative with the exception of…”

Objective                

Vital Signs: Stable

Temp:

            BP:

            HR:

             R:

             O2:

             Pain:

             Ht:

             Wt:

             BMI:

             BMI Range:

LABS:

Lab findings WNL

Tox screen: Negative

Alcohol: Negative

HCG: N/A

Physical
Exam:

MSE:

Patient
is cooperative and conversant,
appears without acute distress, and fully oriented x 4. Patient is dressed appropriately for age and
season. Psychomotor activity appears within normal.

Presents
with appropriate
eye contact, euthymic affect – full, even, congruent with reported mood of “x”.  Speech: spontaneous,
normal rate, appropriate volume/tone with no problems expressing self.

TC: no abnormal content elicited, denies suicidal ideation and denies
homicidal
ideation.
Process appears linear, coherent, goal-directed.

Cognition appears grossly intact with appropriate attention span & concentration and average fund of knowledge.

Judgment
appears fair . Insight appears fair

The patient is able to articulate needs, is motivated
for compliance and adherence to medication regimen. Patient is willing and able to
participate with treatment, disposition, and discharge planning.

This is where the “facts” are located.

Vitals,

**Physical Exam (if performed, will not be performed
every visit in every setting)

Include relevant labs, test results, and
Include MSE, risk assessment here, and psychiatric screening measure results.

Assessment

DSM5 Diagnosis: with ICD-10 codes

Dx:
–   

Dx:
–   

Dx: –   

Patient has the ability/capacity appears to
respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent.

Reviewed potential risks & benefits, Black Box
warnings, and alternatives including declining treatment.

Include your
findings, diagnosis and differentials (DSM-5 and any other medical diagnosis)
along with ICD-10 codes, treatment options, and patient input
regarding treatment options (if possible), including obstacles to treatment.

Informed Consent
Ability

Plan

(Note some items
may only be applicable in the inpatient environment)

Inpatient:

Psychiatric.  Admits to X as per HPI.

Estimated stay 3-5 days

Safety Risk/Plan:  Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal 
risk to others at this time. 

Patient denies abnormal perceptions
and does not appear to be
responding to internal stimuli.

Pharmacologic
interventions: including dosage, route, and frequency and non-pharmacologic:

·         
No changes to current
medication, as listed in chart, at this time

·         
or…Zoloft is an excellent
option for many women who experience any menstrual cycle complaints.  I usually start at 50 mg and move to 100
week 6-8. f/u within 2 weeks initially then every 6-8 weeks.

• Psychotherapy
  referral for CBT

Education,
including health promotion, maintenance, and psychosocial needs

• Importance
  of medication

• Discussed
  current tobacco use. NRT not indicated.

• Safety
  planning

• Discuss
  worsening sx and when to contact office or report to ED

Referrals:
endocrinologist for diabetes

Follow-up,
including return to clinic (RTC) with time frame and reason and any labs that
are needed for next visit 2 weeks

☒ > 50% time spent counseling/coordination of care.

Time
spent in Psychotherapy  18
minutes

Visit lasted 55 minutes

Billing
Codes for visit:  

XX

XX

XX

____________________________________________

NAME, TITLE

Date: Click here to enter a date.    Time: X