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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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Who is primary care provider?
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Symptoms Include
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Symtom Severity (Scale from 1-10
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The patient reports feeling:
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Comments
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Compliance
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ADL'S IMPAIRED
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STAFF REVIEW: Hours sleep:
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Patient Interview
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Sleep
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Comments
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Nutrition
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Comments
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Appetite
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Comments
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Psychotic Symptoms
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Comments
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Requiring redirection
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Comments
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Displaying psychotic symptoms
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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
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Comments
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Current Medications
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PSYCH MEDS
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PRN’s required
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Comment
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Date of medication adjustments
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Medication Concerns per patient
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Comments
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Medication side effects
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Comments
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Chronic medical problems
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Comments
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Acute medical problems
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Comments
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Somatic Concerns
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Other concerns/issues:
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Comments
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Objective:
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PHYSICAL STATUS
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Latest orders/New Lab results
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Comments
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MENTAL STATUS EXAM
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APPEARANCE
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Appearance
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Comments
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SPEECH:
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Speech
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Comments
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BEHAVIOR
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Behavior
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Comments
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Mood/Affect
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AFFECT:
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Comments
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ORIENTATION
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ATTITUDE:
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Thought process/content
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THOUGHT CONTENT:
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THOUGH PROCESS:
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Comments
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ALERTNESS
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FUND OF KNOWLEDGE
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Judgment
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Comemnts
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Insight
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Comments
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Patient’s awareness/insight
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Comments
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ABILITY TO ABSTRACT
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CONCENTRATION
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Cognitive
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Comments
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Suicidal thoughts
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Comments
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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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Sociopathy Risk
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Family Mental Health Hx
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Family MH Hx Narrative
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DRUG HISTORY
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Drugs Current
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DRUG NARRATIVE
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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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Sexual problems/history
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NP’S ASSESSMENT
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Comments
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Affective Symptoms
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Comments
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Behavioral Symptoms
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Comments
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Altered Thoughts/Psychosis
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Comments
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Physical Status
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Comments
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Patient seems
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Comments
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ECG
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PERFORMED BY
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Labs
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Lab Comments
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Blood Draw
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Nurse/MA Performing
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In office venipuncture
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Needle
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Vascular access
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Tolerated procedure well.
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PMP Reviewed
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Point of Care Urine Drug Screen
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Point of Care Urine Drug Screen Done today?
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Point of Care Drug Screen POSITIVE for:
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Point of Care Drug Screen NEGATIVE for:
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OTHER DRUG TESTED:
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Urine hCG
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PERFORMED BY
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PLAN OF TREATMENT
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Plan of Care:
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RATIONALE FOR CONTINUED TREATMENT
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Comments
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DISCUSSION OF MEDICATIONS
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Read
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Follow-Up
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Type of Injection
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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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Recommendations
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Referrals
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Referral Comments
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Staff Notified to Reschedule NP apt.
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Patient/CG verbalizes understanding to POC
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Staff Notified to reschedule/schedule apt. with therapist
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LPN/RN Notified To Place Referral
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Other Information
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Education
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Education Comments
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