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Assessment
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Assessment
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Treatment Plan
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Initial Appointment?
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Client Strengths:
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Barriers to Treatment:
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Follow Up?
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Progression Towards Goals
• • •
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Treatment Plan Comment
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Medications
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Medication Changes
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New Medication
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New Medication Symptom Target
• • •
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Pertinent Side Effects:
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No adverse side effects
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Medication Comments
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Diagnosis Attestation
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PDMP Attestation
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Labs
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Date of Last Lab
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Previous Findings
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Labs Reviewed
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Labs
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Lab Orders:
• • •
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Lithium Lab
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Valproic Acid Lab
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Carbamazepine Lab
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Lamotrigine Lab
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Referrals
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Referral
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Referred to:
• • •
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Referral Comments:
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Follow Up
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Follow Up
• • •
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Follow Up Comments
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Education
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Patient Education:
• • •
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Education Comment:
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Declined Treatment
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Suicidal Ideation/No Hospitalization
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Substance Dependence Warning
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Illicit Drug Use
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Diet
• • •
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Dietary Comments:
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Additional Treatment Plan Comments:
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Informed Consent
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Informed Consent Comments:
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Coordination of Care
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Coordination of Care
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Release of Information:
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Medical Decision Making
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Straightforward MDM (99202/99212):
• • •
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Low MDM (99203/99213):
• • •
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Moderate MDM (99204/99214):
• • •
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High MDM (99205/99215):
• • •
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