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Chief Complaint / Reason for Encounter:
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Chief Complaint / Reason for Encounter:
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CC explained
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Problem Status
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Identified Problem
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Problem Status
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Identified Problem
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Problem Status
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Identified Problem
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Verbal consent for Telehealth
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Patient location
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Patient location city/state:
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Medical HX
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Medical HX
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Family HX
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Family HX
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Social HX
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Social HX
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Side effects
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Description of side effects
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Drug Interactions
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Description of Interactions
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Appetite
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Sleep pattern
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Mental Status
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Appearance
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Appearance comments
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Behavior / Attitude
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Behavior comments
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Eye contact
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Eye comments
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Motor activity
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Motor activity comments
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Mood (inquired):
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Mood comments
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Affect (observed):
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Affect comments
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LOC:
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LOC comments
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Attention / Cocentration:
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7's/spell backwards/Trail making (1A2B3C)
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Memory:
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Memory comments:
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Orientation
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Speech (Volume & Tone):
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Thought Process: Generally apparent throughout the encounter
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Other findings:
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Thought content: What is the patient thinking?
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Other findings:
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Fund of Knowledge
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other findings
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Judgement
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Insight
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Describe hall/del/SI/HI
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Homicidal ideation for now and future
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Suicidal ideation for now and future
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Plans for the future
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Hallucinations
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Types of hallucinations
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Delusions
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Types of delusions
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Other findings (cognitive screens):
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Treatment Plan
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Medication regimen
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Rx regimen comments
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Education provided
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Med complaince
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ILPMP is verified and consistent with rx
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Patient to follow up:
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Referrals or Labs
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Start Time:
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End time:
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