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GIVEN COVID 19 PANDEMIC, TODAYS ENCOUNTER
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Covid 19 creening
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New Free Draw
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New Free Draw
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Reason for today's visit
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Other reason for visit
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Duration since last office visit
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Current stressors
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I am taking prescribed medication
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My mood since last appointment is
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In general, I feel my
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My Anxiety symptoms
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My Depression symptoms
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Adverse effects of medication
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New Short Text Field
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Family and social history
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My Family History
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Social History -Current living conditions
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School Name / Grade - academic performance-
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Review of Symptoms
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Sleep
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Appetite
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Concentration and focus
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Abitity to enjoy things
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Motivation
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Nervous system symptoms
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GAI-Measurement of current anxiety symptoms
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New Free Draw
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I worry a lot of the time.
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I find it difficult to make a decision.
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I find it hard to relax.
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I often feel jumpy.
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I often cannot enjoy things because my worries.
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Little things bother me a lot
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I think of myself as a worrier.
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I often get butterflies in my stomach.
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I can't help worrying about trivial things.
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I often feel nervous.
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I get an upset stomach due to my worrying.
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My own thoughts often make me nervous.
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I think of myself as a nervous person.
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I always anticipate the worst will happen.
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I think that my worries interfere with my life.
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I often feel shaky inside.
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My worries often overwhelm me.
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I sometimes feel a great knot in my stomach.
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I often feel upset.
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I miss out on things because I worry too much.
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Score:
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Interpreting Score
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PHQ9 Depression screen -in past 2 weeks have you felt
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Loss of Interest/pleasure doing things
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Trouble falling asleep ,staying asleep or sleeping too much
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Trouble Concentrating?
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Poor appetite or overeating?
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Feeling down, depressed or hopeless?
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Feeling bad about oneself?
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Feeling tired or having little energy?
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Feeling slowed down or fidgety & restless?
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Thoughts you are better off dead or considering self harm?
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If I have suicidal thoughts -
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PHQ 9 Score
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In the past few weeks, have you wished you were dead or wish that you could go to sleep and not wake up?
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In the past FEW weeks, have you been having thoughts about killing yourself?
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In the past few weeks, have you felt that either you or your family would be better off if you were dead?
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Have you EVER tried to kill yourself or made a suicide attempt
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Counseling or Acceptance Commitment Therapy
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New concerns/symptoms
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Image of Completed PHQ & GAI
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CRAFFT - During the past 12 months
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Drinking alcohol (more than a few sips)?
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How Often
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Tobacco Use
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Comments
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Any marijuana or byproducts of marijuana?
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Please list products used and how often / week
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Do you ever use alcohol or drugs to relax, feel better about yourself, or to fit in?
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Do you ever forget things you did while using alcohol or drugs?
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Use anything else to get high?
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Please list products used and how often / week
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Have you ever ridden in a car driven by someone who was high or had been drinking?
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Have you ever gotten into trouble while you were using alcohol or drugs?
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Comments
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STOP-PLEASE RETURN IPAD TO DESK
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Physician Examination
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Mental Status Exam
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Normal Menta status exam
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Mental status w dec eye cont, insight , sullen
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Physical exam
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NORMAL PHYSICAL EXAM
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General WNL
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General Comments
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Neuro WNL
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Neuro Comments
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Mood
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Mood
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Affect WNL
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Affect abnl
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Speech/Language WNL
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Speech abnl
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Thought Process WNL
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Thought process abnl
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Thought Content WNL
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Thought content comments
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Perception WNL
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Perception abnl
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Cognition WNL
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Cognition abnl
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Judgment/Insight WNL
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Judgment abnl
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Insight abnl
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Judgment/insight comment
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Memory WNL
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Memory abnl
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PHQ9 Scoring
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Physician PHQ9 interpretation
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Suicide intent
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Homicidal intent
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Assessment and Plan
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Image of Completed PHQ & GAI
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Image of Completed PHQ & GAI
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Depression Assessment /Plan
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Anxiety Assessment /Plan
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on this day( physician time )
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Total Encounter time inc activites b4 /after documentation
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Additional Psych diagnosis / management
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Assessment /Plan ANX Dep
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Total Encounter time inc activites b4 /after documentation
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Psych TX opt , risk, benefit ,comp, abrupt cess
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Addn se -gi/nerv/psych/suicide/wt/
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A/p OTHER id cond.c/0 etc req phys E&M
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Risk of abrupt cessation or inconsistent -psych
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Antipsychotoic se, risk ,emerg, IC
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New Free Draw
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Risk of noncompliance or abrupt cessation
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How often
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Assessment /Plan -no content
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New Free Draw
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Negative Anxiety evaluation
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General Instructions for wellness
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i spent 60' review chrt , ov, doc and coord of care
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Therapeutic measures discussed
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Education provided during office visit ..
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*Addn Psych plan inc dep scale reviews etc
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Tx Interventions
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> 30 min Face to Face Counseling Techniques utilized include
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Over 50 % of the
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A/P Nutritional counseling
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General Instruction Comments
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Skip down to family and social history section
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Education Comments
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Therapy
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In the past few weeks, have you experienced any of the following feelings? (Please check all that apply)
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Other relative physical exam findings
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Physician time spent counseling
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Physician completed following
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Follow Up
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General AG provided
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A/P-90872,96130,90832,59, 98960
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Overall effectiveness
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Current Stresses
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Attending Counseling or Acceptance Commitment Therapy
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Reason for follow up visit
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Dysfunctional sleep patterns
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Family History (anxiety, depression, bipolar ?
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Speech/lang comments
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List your diagnoses and medications
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Diet
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When approximately was dose last adjusted
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Counseling - where and with whom ?
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Do your family or friends ever tell you that you should cut down on your drinking or drug use?
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Comments
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Comments
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Language abnl
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How often?
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Cognition comments
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Perception comments
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INS-Patient /parent gave verbal consent
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A ) PSYCHIATRIC DIAGNOSTIC EVALUATION AND MEDICAL SERVICES Anxiety/ Depression - Current diagnosis and treatment reviewed.. P
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Psych physical and mental examination
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free text
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chk for all ASSESSMENT /PLAN
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A/P GI n/v/d/c/abd pain
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Affect comment
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Is yes, what was used?
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New Free Draw
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Counseling - where and with whom ?
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Homicidal intent
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Skin
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