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Appointment Date/Time
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Total Encounter Time
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Referral Source
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Interval History
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Patient Subjective
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Patient notes not for locked note
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Severity of depression
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Severity of anxiety
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Severity description
• • •
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Severity notes
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Pertitent negatives
• • •
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Pertinent negative notes
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Side effects from medications
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Medication side effects
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Adherence to treatment plan
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Adherence notes
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Orignial HPI
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Prior Appointment HPI
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Current Appointment HPI
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Psychotherapy
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Social History
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Born/Raised
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Family of origin/relationship with parents
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Developmental History:
• • •
|
Developmental history notes
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Learning disabilities
• • •
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Learning disability notes
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Current living situation
• • •
|
Living situation notes
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Relationship status
• • •
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Relationship with partner
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Children
• • •
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Relationship with children
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Siblings
• • •
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Relationship with siblings
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Hobbies that bring joy
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Birth order
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Social Support
• • •
|
Social support note
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Highest Level of Education
• • •
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Schooling notes:
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Occupation status
• • •
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Occupation notes:
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|
Military
• • •
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Arrests
• • •
|
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Religious history
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|
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Current legal issues
|
Legal notes
|
|
Family Psychiatric History
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|
|
Known Family Psych/Substance History
• • •
|
Family Psych History Notes
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|
Family Psychiatric Hospitalizations
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Hospitalization Notes
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|
Suicide completed close to you
|
Completed Suicide Notes
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|
Patient Psychiatric History
|
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Diagnosis
• • •
|
Diagnosis Notes
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Current Psychiatric Medications
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Past Medications, Timeframe, and Response
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|
Past psychiatric hospitalizations
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Hospitalization Notes
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|
History of Trauma/Abuse
|
History of Trauma
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Outpatient Treatment/Therapy
|
Outpatient Treatment Notes
|
|
History of ECT?
|
History of TMS?
|
|
History of Ketamine
|
History of TMS, Ketamine, ECT Comments:
|
|
Medical History
|
|
|
Medication allergies
|
Medication Allergies
|
|
Current medical problems
|
Medical Problems
|
|
History of seizures
|
Seizures notes.
|
|
History of asthma
|
Asthma notes
|
|
Current non-psychiatric medications
|
Current Non-Psychiatric Medications
|
|
Vitamins/Supplements
|
Vitamins/Supplements
|
|
Surgical History
|
Surgical History
|
|
Head Injuries
|
Head Injuries
|
|
Substance History
|
|
|
Alcohol history/use
|
Alcohol notes
|
|
Tobacco history/use
|
Tobacco notes
|
|
Marijuana history
|
Marijuana notes
|
|
Methamphetamine history/use
|
Methamphetamine notes
|
|
Cocaine history
|
Cocaine notes
|
|
Opiate history
|
Opiates notes
|
|
Other substance history
|
Other substances notes
|
|
Suicide Risk Assessment
|
|
|
SI/HI/DTO/DTS
• • •
|
SI/HI Comments
|
|
Suicidal protective factors
• • •
|
Suicide Risk Factors
• • •
|
|
Suicide Prevention Addressing Sx
• • •
|
Suicide Prevention Addressing Risk
• • •
|
|
Suicide Prevention Addressing Diagnoses
• • •
|
|
|
Psychiatric Review of Symptoms
|
|
|
Depression
• • •
|
Depression notes
|
|
Bipolar Disorder
• • •
|
Bipolar notes
|
|
Anxiety
• • •
|
Anxiety notes
|
|
Sleep disturbances
• • •
|
Sleep notes
|
|
ADHD
• • •
|
ADHD notes
|
|
PTSD
• • •
|
PTSD notes
|
|
OCD
• • •
|
OCD notes
|
|
Mental Status Exam
|
|
|
Appearance
• • •
|
Orientation
• • •
|
|
Memory
• • •
|
Concentration and attention
• • •
|
|
Behavior
• • •
|
Mood
• • •
|
|
Affect
• • •
|
Psychomotor
• • •
|
|
Speech
• • •
|
Thought Process
• • •
|
|
Thought content
• • •
|
Insight (awareness)
• • •
|
|
Judgment (avoid situations)
• • •
|
Cognition
• • •
|
|
Hallucinations
• • •
|
Delusions
• • •
|
|
Treatment Plan
|
|
|
PMP Aware
• • •
|
Labs
• • •
|
|
Medications
|
|
|
Follow-up
|
Therapy
|
|
Non-pharmacological recommendations
• • •
|
Homework
|
|
Tests
• • •
|
Vitamins/OTC
• • •
|
|
Diagnostic Formulation
|
|
|
Informed Consent
• • •
|
Consent
|
|
Counseling & Coordination of Care
• • •
|
Management options
• • •
|
|
Problem Points
• • •
|
Review of data
• • •
|
|
Risk and complexity Level
• • •
|
|
|
Impression
|
|
