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Header Information
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Telepsychiatry
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Date of initial consult or first appt with you :
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Patient Quote:
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Subjective hx:
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Depression
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Anxiety
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ADHD
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Bipolar
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PTSD
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Patient denies
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Labs/Vitals/ROS Assessment:
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Labs:
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Labs (if abnormal, explain):
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Vitals:
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Review of Systems:
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Alcohol/ Illicit Drug Assessment:
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Pt Denies Alcohol/Illicit Drug Use:
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If no, please specify substance, frequency, amount:
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E/M Assessment:
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Current Medication:
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Medication Side Effects:
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If Medication Side Effects, explain:
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Medication Compliance:
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If Pt is NOT medication compliant, explain:
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CURES Reviewed
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Additional Cures Info
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MSE:
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Appearance:
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A & O:
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Behavior:
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Speech:
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Affect:
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TP:
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Cognition:
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Pt quote about Cognition:
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Judgement
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Insight
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Mood
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Pt subjective quote about Mood:
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SI:
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SI
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Contracts for Safety
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HI
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HI
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Psychosis
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Specify psychotic symptoms
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PHQ-9
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PHQ-9 Score
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GAD-7
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GAD-7 Score
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Diagnostic Impression:
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DI: Major Depressive Disorder
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DI: Psychotic Disorders
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DI: Other Disorders
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DI- Substance Use Disorders:
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DI- ADHD
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DI: Bipolar
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DI: Eating Disorders
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DI: Cognition
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DI: (If not listed as favorite above)
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TMS/Spravato Discussed?
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If TMS/Spravato discussed, explain:
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Risk/ Benefits for Referral
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Clear Recovery Center Discussed?
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If CRC was discussed, explain:
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Progress/Assessment/Treatment Planning:
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Assessement:
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Therapeutic Intervention Used
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Problem List
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Pt Progressing with therapy:
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EVIDENCE OF PROGRESS OR NEW TX PLAN
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Therapy Treatment Plan
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Additional therapy plan details
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Any medication changes?
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Specify medication changes or addt'l Tx planning.
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Additional treatment plans:
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Med/Meds Prescribed
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Follow Up:
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CPT
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Appointment Length
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Psychotherapy Start Time:
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End Time (MUST MEET 90833/36 CPT CRITERIA):
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Risks/Benefits Statement
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Supervisor of PMHNP
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