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Assessment type
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Telehealth
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Chief Complaint
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Information provided by
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Patient states
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Today patient states there is
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Current stressors
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Your goals for treatment?
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Is patient a current smoker?
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Smoking Cessation discussed
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Medication Management
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Current Medications
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Medication Side Effects
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Medication Changes:
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Medication notes
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Labs
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PMP Checked
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Education
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The patient was counseled and educated on
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Any new or persistent physical complaints
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Comments
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Have you spoken to your primary care provider about this
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Will you
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ROS
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Pt has symptoms of/ problem pertinent ROS
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Eating well
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free text regarding appetite
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Sleeping well
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free text regarding sleep
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Caring for personal needs
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Taking care of responsibilities, i.e. housework, home, or school
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Depression
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Depression symptoms
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Depression is
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Depression symptoms related to substances
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free text regarding depression
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Bipolar Disorder
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Bipolar disorder symptoms
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Mania is
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free text regarding mania
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ANXIETY
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Generalized anxiety disorder sympotms
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Generalized Anxiety Disorder Symptoms
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Anxiety is
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Anxiety symptoms related to substances
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free text regarding anxiety
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ADJUSTMENT DISORDER
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Accompanying mood
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free text regarding adjustment disorder
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Social Anxiety
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social anxiety/social phobia symtpoms
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social anxiety is
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free text regarding social anxiety
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PTSD
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PTSD symptoms
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PTSD is
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free text regarding PTSD
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OCD
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OCD symptoms
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free text regarding OCD
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ADHD
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ADHD symptoms
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Symptoms occur
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ADHD is
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free text regarding ADHD
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AUTISM SPECTRUM
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Autism spectrum symptoms
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Severity of autism symptoms
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Accompanied by
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free text regarding autistic disorder
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ANGER/AGGRESSION
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ANGER/AGGRESSION
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free text regarding anger
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Chemical Dependency
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CHEMICAL DEPENDENCY
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Drugs of abuse
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free text regarding chemical dependency
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chemical dependency treatment
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free text regarding chemical dependency treatment
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Conduct Disorder
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Conduct disorder symptoms
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free text regarding conduct disorder
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ODD
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ODD symptoms (children)
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free text regarding ODD
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Eating Disorder
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Eating disorder
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free text regarding eating disorder
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Personality Disorder
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PERSONALITY DISORDER
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Grief/Loss
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Grief explained
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Cognition/dementia
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Orientation impairment
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Judgment
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Insight
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Memory impairment
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Mental Status Exam
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Observations
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Appearance
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Behavior
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Speech rate
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Speech Fluency
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speech spontaneity
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Speech volume
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Eye Contact
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Motor Activity
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Affect
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Mood
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Thought Content
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Delusions described
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Thought Processes
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Thought processes described
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IQ
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Gait is normal and station is erect
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Drug withdrawal or intoxication is currently present
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Perception
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Hallucinations
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Derealization/Depersonalization
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Safety
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Suicidality
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Plan
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Intent
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Self-harm
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Hospital referral needed for injuries
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Homicidality
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Plan
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Internal coping strategies
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People and social settings that provide distraction
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People who I can ask for help
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Professionals or agencies I can contact during a crisis:
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Hospitals with psychiatric services
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Create a safe environment
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Instructions/recommendations/plans
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The following level of care is recommended
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Therapeutic Interventions
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Therapy modalities used today
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Therapy content/Clinical summary
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Today the patient focused on feelings of
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Focus of therapy today was
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Therapeutic efforts focused on
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The patient was counseled and educated on
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Interventions Introduced
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Response to Intervention
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Plan for next session/homework free text
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Referrals
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Return appointment
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Barriers to treatment
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What are the barriers to treatment
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Physical Barriers to Treatment
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What are the physical barriers to treatment
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Describe your supports
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What strengths help you?
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Progress
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Medical Decision Making
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Low complexity
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Medium Complexiety
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High Complexiety
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