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Informants
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Informants Explained
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Contact Methods
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Message Permission
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Marital Status
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How many times married?
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Currently lives with?
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Narrative of Living Situation:
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Race
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Other Pertinent Demographics
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Chief Complaint
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History of the Present Illness
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Symptoms Include
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Symtom Severity (Scale from 1-10
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When did symptoms begin?
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Symptom frequency
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Nature of Symptoms Narrative
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Patient has tried
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APPEARANCE
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BEHAVIOR
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ORIENTATION
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MEMORY
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ATTITUDE:
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SPEECH:
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MOOD (subjective):
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AFFECT:
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THOUGHT CONTENT:
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THOUGH PROCESS:
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ALERTNESS
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INSIGHT
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JUDGEMENT
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ABILITY TO ABSTRACT
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CONCENTRATION
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FUND OF KNOWLEDGE
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Current Meds--Go to MENU TAB
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Current Safety Issues
• • •
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Leathality
• • •
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Narrative/Intervention RE: Safet
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History of Suicide Attempt
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Suicide Attempt Narrative
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MH Treaters seen?
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Psychiatric treatment-in/outpt?
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any prenatal dev issu as child
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Sociopathy Risk
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Family Mental Health Hx
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Family MH Hx Narrative
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Family Constellation
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Family of Origin Narrative
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DRUG HISTORY
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Drugs Current
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DRUG NARRATIVE
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HX of Withdrawal/Toxicity Proble
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Hx of Support Groups
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Has sponsor?
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Sexual orientation
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Sexual problems/history
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TRAUMA/ABUSE HISTORY
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Abuse narrative
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Hx of Violence
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Hx of Violence Narrative:
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Occupation:
• • •
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Occupation/Emplymnt Status/Hx Na
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Who is primary care provider?
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PCP phone number
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Other MD's? Specialty?
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Pharmacy? Phone Number
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Past Meds
• • •
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Clinically relevant Adherence Pr
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Medications Narrative
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Maintenance Program Cont'
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Maintenance Programs
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Dose Veriacity
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Allergies
• • •
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Allergy Narrative
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PAST/CURRENT MEDICAL PROBLEMS
• • •
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MEDICAL PROBLEM HX NARRATIVE
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Past Surgeries?
• • •
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Surgery Narrative
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Head Trauma
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Head Trauma Narrative
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Pregnant?
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OB/GYN History/Issues?
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Date of LMP?
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ADL'S IMPAIRED
• • •
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How do you get along with peers?
• • •
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Legal Hx?
• • •
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Legal Narrative
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Recent Separation/Losses?
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Recent Separation/Losses Narrati
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Axis I
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Axis II
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Axis III
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AXIS IV
• • •
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Axis IV-narrative
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Axis V
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Recommendations
• • •
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DISCUSSION OF MEDICATIONS
• • •
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Prescription given today
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Prescription given today
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Prescription given today:
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Prescription given today
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Further Plans:
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Referrals
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CPT CODE
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APRN's signature
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Psychiatrist notes
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