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EIN/ NPI
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CPT
• • •
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Identifying Data:
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Referred by:
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Date of Current Episode
|
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Chief Complaint/Presenting Problem:
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HPI
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HPI Symptoms:
• • •
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Current Rating Scales
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PHQ- 9 Score:
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QIDS
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GAD-7
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YBOC
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WHO-5 Score
|
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Discussion of Treatments
• • •
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Past Psychiatric History:
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H/O Hypomania/Manic Episodes
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H/O Inpatient/ Residential Treatment:
|
If H/O Inpatient/ Residential Treatment, explain:
|
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H/O PHP/IOP:
|
If H/O PHP/IOP, explain:
|
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H/O Suicide Attempts:
|
If H/O Suicide Attempts, explain:
|
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H/O Addiction:
|
If H/O Addiction, explain:
|
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Prior Psychiatric Medication:
|
If prior psychiatric medication, explain:
|
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H/O TMS:
|
If H/O TMS, explain dates & response:
|
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H/O Ketamine:
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If H/O Ketamine, explain dates & response:
|
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H/O ECT:
|
If H/O ECT, explain dates & response:
|
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Therapy
|
Provider 1
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Dates:
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Type:
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Outcome:
|
Current/ Past Psychiatrist:
|
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Family History:
• • •
|
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Past Medical History
|
Additional Past Medical History
|
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Current Medications
|
CURES Reviewed
|
|
Medication Compliance:
|
If Pt is NOT medication compliant, explain:
|
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Allergies:
|
PE/Labs:
|
|
Social History:
|
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Marital Status:
|
Living Situation
|
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Lives with...
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Education:
|
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Employment:
|
Family/ Social Support:
|
|
Skills, Abilities, Motivation:
|
Father:
|
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Mother:
|
Siblings:
|
|
Habits:
|
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Tobacco:
|
If Pt uses tobacco, explain:
|
|
Alcohol:
|
If Pt uses alcohol, explain:
|
|
Marijuana:
|
If Pt uses marijuana, explain:
|
|
Illicit Drugs:
|
If Pt uses Illicit drugs, explain:
|
|
IVDA:
|
If IVDA, explain:
|
|
Mental Status Exam
|
|
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Appearance:
• • •
|
A & O:
|
|
Behavior:
• • •
|
Speech:
• • •
|
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Affect:
• • •
|
TP:
• • •
|
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Cognition:
|
Insight
|
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Judgement
|
|
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Mood
• • •
|
Mood (Patient Quote)
|
|
SI:
|
SI
|
|
Contracts for Safety
|
|
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HI
|
HI
|
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Psychosis
|
|
|
Auditory Hallucinations
|
Auditory Hallucinations
|
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Visual Hallucinations
|
Visual Hallucinations
|
|
Suicide Risk Assessment
• • •
|
|
|
Suicide Risk Factors
• • •
|
Protective Factors:
• • •
|
|
Diagnostic Impression:
|
|
|
DI: Major Depressive Disorder
• • •
|
DI: Other Disorders
• • •
|
|
DI- Substance Use Disorders:
• • •
|
DI- ADHD
• • •
|
|
DI: Bipolar
• • •
|
DI: Eating Disorders
• • •
|
|
DI: Cognition
|
DI: (If not listed as favorite above)
|
|
Assessment of Severity:
|
|
|
Outpatient Care Appropriate
|
If outpatient care is NOT appropriate, recommended:
• • •
|
|
Treatment Recommendations
• • •
|
Therapy Treatment Recommendations
• • •
|
|
Additional Recommendations
|
|
|
Preventative/ Ancillary Services recommended:
• • •
|
|
|
Risk/ Benefits
• • •
|
|
|
Discharge Planning/ Patient Rights
|
|
