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Assessment type
• • •
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Chief Complaint:
• • •
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Other Chief Complaint
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HPI:
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Compliance
• • •
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STAFF REVIEW: Hours sleep:
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Nutrition
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Comments
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Requiring redirection
|
Comments
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Displaying psychotic symptoms
|
Comments
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Inappropriate behaviour
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Comments
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Unstable affect/mood
• • •
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Comments
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Compared to initial presentation
|
Comments
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PRN’s required
|
Comment
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PHYSICAL STATUS
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Chronic medical problems
|
Comments
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Acute medical problems
|
Comments
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Latest orders/New Lab results
|
Comments
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Current Medications
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PSYCH MEDS
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Date of medication adjustments
|
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Medication Concerns per patient
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Comments
|
|
Medication side effects evident
• • •
|
Comments
|
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Type of Injection
• • •
|
Injection Comments
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Location
• • •
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Number of Sites
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Needle
• • •
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Tolerated Well
|
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GIVEN BY
|
|
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Patient Interview
|
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Appetite
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Comments
|
|
Sleep
|
Comments
|
|
The patient reports feeling:
• • •
|
Comments
|
|
Psychotic Symptoms
• • •
|
Comments
|
|
Patient’s awareness/insight
|
Comments
|
|
Somatic Concerns
|
|
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Other concerns/issues:
• • •
|
Comments
|
|
MENTAL STATUS EXAM
|
|
|
Appearance
• • •
|
Comments
|
|
Speech
• • •
|
Comments
|
|
Behavior
• • •
|
Comments
|
|
Mood/Affect
• • •
|
Comments
|
|
Thought process/content
• • •
|
Comments
|
|
Judgment
• • •
|
Comemnts
|
|
Insight
• • •
|
Comments
|
|
Cognitive
• • •
|
Comments
|
|
Suicidal thoughts
• • •
|
Comments
|
|
NP’S ASSESSMENT
|
Comments
|
|
Affective Symptoms
• • •
|
Comments
|
|
Behavioral Symptoms
• • •
|
Comments
|
|
Altered Thoughts/Psychosis
• • •
|
Comments
|
|
Physical Status
• • •
|
Comments
|
|
ECG
|
PERFORMED BY
|
|
Labs
• • •
|
Lab Comments
|
|
Blood Draw
|
Nurse/MA Performing
|
|
In office venipuncture
|
Needle
|
|
Vascular access
|
Tolerated procedure well.
|
|
Point of Care Urine Drug Screen
|
Point of Care Urine Drug Screen Done today?
|
|
Point of Care Drug Screen POSITIVE for:
• • •
|
Point of Care Drug Screen NEGATIVE for:
• • •
|
|
OTHER DRUG TESTED:
|
|
|
Urine hCG
|
PERFORMED BY
|
|
Patient seems
• • •
|
Comments
|
|
RATIONALE FOR CONTINUED TREATMENT
• • •
|
Comments
|
|
PLAN OF TREATMENT
• • •
|
Comments
|
|
Referrals
|
Referral Comments
|
|
Staff Notified to Reschedule NP apt.
|
Patient/CG verbalizes understanding to POC
|
|
Staff Notified to reschedule/schedule apt. with therapist
|
LPN/RN Notified To Place Referral
|
|
Other Information
|
PMP Reviewed
|
|
99213 (Problems=3,Data =1. Risk=low)
|
99214(Problems =4, Data =2, Risk=Moderate)
|
|
99215 (Problems =5, Data = 4, Risk =High)
|
|
