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Subjective
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Today, patient... ******
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Sleep *****
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Appetite *****
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Energy *****
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Compliance to Medication is *****
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Side Effects to psychotropics reported *****
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Objective
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Video Visit
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General Appearance:
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Attitude & Behavior:
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Psychomotor
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Speech:
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Mood:
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Affect:
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Thought Content:
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Thought Process:
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Perception:
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Hallucination Content:
|
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Sensorium:
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Cognition:
|
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Impulse Control:
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Insight:
|
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Judgement:
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LAB & DIAGNOSTICS
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|
|
LAST SESSION PSYCHOTROPIC MEDICATIONS:
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Phone Visit Only
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General Appearance:
|
Attitude & Behavior:
|
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Psychomotor
|
Speech:
|
|
Mood:
|
Affect:
|
|
Thought Content:
|
Thought Process:
|
|
Perception:
|
Hallucination Content:
|
|
Sensorium:
|
Cognition:
|
|
Impulse Control:
|
Insight:
|
|
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Judgement:
|
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LAB & DIAGNOSTICS
|
|
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LAST SESSION PSYCHOTROPIC MEDICATIONS:
|
|
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Assessment & Plan
|
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BIOLOGICAL TREATMENT:
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1.
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2.
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Benefits/Risks/Alternatives were addressed
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Informed consent was obtained and filed
|
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Patient advised to bring back metabolic syndrome info
|
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PSYCHOSOCIAL TREATMENT:
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Provided Supportive/ Educational therapy
|
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Provided Intervention
|
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Client Response
|
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|
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1: 1 Psychotherapy
|
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Medical Necessity of Office Visit
|
|
|
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Session Time in minutes
|
|
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Documentation Time in minutes
|
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Return to Clinic in weeks
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