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Identifying Information
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DID PT TAKE MEDS AS INSTRUCTED?
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If No, why not? (use patient's words)
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DID PT USE DRUGS/ETOH SINCE LAST VISIT?
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If yes, what substance?
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Amount used (dose/unit... 30/MG)
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When and why? (use "patient's words")
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DID PT EXPERIENCE MED SIDE EFFECTS?
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If yes, what side effects?
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DID PT HAVE WITHDRAWALS SINCE LAST VISIT?
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If yes, withdrawals include:
• • •
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Timing of symptoms
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Duration of symptoms
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Severity of symptoms
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Comment:
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DID PT HAVE CRAVINGS since last visit?
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If yes, when?
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Duration of cravings
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Severity of cravings
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Reported hours of sleep
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Sleep quality/outcome
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Patient's current mood
• • •
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Comment
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DID YOU RECORD PATIENT VITALS?
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Positive Drug Screen?
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Positive Drug Screen
• • •
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BAC
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General WNL
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General ABN
• • •
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Chronic Medical Issues
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Medical issues comments:
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Is Gait NORMAL? [-]
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Gait Comments:
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Is Rhomberg NEGATIVE? [-]
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Station Comments:
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Mental Status Exam:
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Arrival to office
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Personal appearance
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Appearance - clothing
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Comments:
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Appearance - age
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Comments:
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Attitude/behavior:
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Comments:
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Speech:
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Comments:
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Eye Contact
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Comments:
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Mood:
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Comments:
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Affect:
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Comments:
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Thought Process:
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Comments:
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Thought Content:
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Thought Content includes:
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Perception:
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Perceptions of:
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Orientation:
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Comments:
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Memory:
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Comments:
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Attention and Concentration
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Comments:
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Insight:
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Comments:
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Judgement:
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Comments:
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Suicidal risk present?
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If YES, Suicidal risk:
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Homicidal risk present?
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If YES, Homicidal risk:
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Patient Currently Stable?
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Condition change?
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Treatment Progress
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Status Comments:
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Diagnosis
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Axis I:
• • •
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comment
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Axis II:
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comment
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Axis III:
• • •
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comment
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Axis IV:
• • •
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comment
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Axis V:
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comment
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Plan of Care
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Plan support
• • •
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Patient educated?
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Patient Agree to continue?
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Comments
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Labs
• • •
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Lab comments
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ADJUST Detox taper?
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If Yes, Taper adjustments
• • •
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Are PRN Meds NEEDED?
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Treatment Instructions provided?
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Instructions provided to support member?
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Follow up
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Referrals
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Referral (to who, for what?)
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