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Type of Appointment:New Intake
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This visit was conducted via telehealth utilizing the DrCHRONO Telehealth platform which is HIPAA compliant.
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Consent
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DrChrono Video Visit
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Patient’s Physical Location
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Provider’s Physical Location
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Participants in this telemedicine visit other than the patient/provider included
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This visit started at
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and concluded at
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There were no complications with technology during this visit.
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Total time spent on one or more of the following
• • •
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___ minutes.
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Chief Complaint
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PATIENT IDENTIFICATION: PATIENT NAME is a AGE y.o GENDER, who presents for initial evaluation visit.
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Reason seeking BH Services
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MARITAL STATUS
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with PMHx of:
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and PPHx diagnoses of
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Patient was seen for intake on DATE and diagnosed with the
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Patient presents today to establish care.
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PSYCHIATRIC SYMPTOMS
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Psychosis
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Mood disorders
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Eating disorders
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Anxiety disorders - PTSD
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Anxiety disorders - Panic Disorder
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Anxiety disorders - OCD
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ADHD
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Past Behavioral Health History
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Inpatient psychiatric hospitalizations
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Suicide attempts
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SIB
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Family psychiatric history
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Past prescriber
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Therapist
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Medication Trials
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Suicide Risk Assessment
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In the past month, have you wished you were dead or wished you could go to sleep and not wake up?
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In the past month, have you actually had any thoughts of killing yourself?
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Have you ever done anything, started to do anything, or prepared to do anything to end your life?
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CSSRS CALCULATED SUICIDE RISK SCORE
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Suicide Protective and Risk Factors
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Suicide Protective Factors
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Suicide Risk Factors
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Trauma History
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Physical Abuse
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Sexual Abuse
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Neglect
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Exploitation
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Medical History
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Surgical History
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Current Medications
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Allergies
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Substance Abuse History
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Current use of alcohol
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Current use of drugs
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Past abuse of
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Past dependence on
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MENTAL STATUS EXAMINATION
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1. GENERAL
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2. MOOD
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3. AFFECT
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4. SPEECH
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5. THOUGHTS
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6. THOUGHT CONTENT
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7. SENSORIUM
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8. COGNITION
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9. MEMORY
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10.PERCEPTION
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11.INSIGHT
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12.JUDGMENT
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13. BEHAVIOR/PSYCHOMOTOR
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Medical Review of Systems
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Pain Assessment
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CONSTITUTIONAL
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MUSCULOSKELETAL
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CARDIAC
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PULMONARY
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NEUROLOGIC
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GASTROINTESTINAL
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REPRODUCTIVE HEALTH
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Birth Control
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Concerns for pregnancy
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MARITAL STATUS
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with PMHx of:
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and PPHx diagnoses of
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Patient was seen for intake on DATE and diagnosed with the
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Diagnosis/Assessment/Plan
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Patient Stated Goals:
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Psychotherapy Recommendations
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LABS
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Medical Issues
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- Continue regular follow-up with PCP for routine health maintenance and any interval health concerns.
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- Continue to monitor for potential medical contributions to psychiatric symptoms (e.g., thyroid function, vitamin D deficiency
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Safety
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- No acute safety concerns identified today.
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- Patient is aware to contact the clinic for interval worsening of symptoms or failure to improve. The patient was educated abou
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- I also informed the patient that I can be contacted via the patient portal for non-urgent issues, and that via the portal the
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- Lifestyle Treatment Recommendations and Self-Care Strategies: Previously discussed and remain an important part of ongoing tre
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- Discussed the importance of eating a healthy, balanced diet, as well as the benefits of regular moderate-intensity exercise (i
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- Discussed the importance of good sleep hygiene and attempting to get 6-8 hours of restful sleep each night.
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- Discussed benefits that relaxation, mindfulness, meditation, and spiritual practice can have on mental health and stability,
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-The patient was educated about the risks versus benefits of the medications prescribed and consents to treatment with these med
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PSYCHOTHERAPY
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At least ___ minutes of supportive psychotherapy was provided in the form of risk reduction using MI techniques and psycho
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FOLLOW UP: Plan to follow up in ___ via telehealth appointment with this provider.
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The patient agrees to contact me with any concerns or problems prior to our next visit.
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