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Initial Consult Date
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Last in person appointment
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Pronouns
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SUBJECTIVE
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Interval Events
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Subjective comments
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Appetite
• • •
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Sleep
• • •
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Energy
• • •
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Aggression
• • •
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Fam, Soc Hx
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New meds since last visit
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Med Side Effects
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Substances
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OBJECTIVE
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MENTAL STATUS EXAM
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Mental Status Dictate
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General Appearance
• • •
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General appearance comments
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Behavior
• • •
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Behavior comments
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Motor
• • •
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Motor comments
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Gait
• • •
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Gait Comments
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Affect
• • •
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Affect comments
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Mood
• • •
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Mood comments
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Speech
• • •
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Speech Comments
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Thought Process
• • •
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Thought Process comments
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Associations
• • •
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Associations comments
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SI
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SI comments
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HI
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HI comments
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Hallucinations
• • •
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Hallucinations comments
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Delusions
• • •
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Delusions comments
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Phobias:
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Obsessions/Compulsions
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FOK
• • •
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FOK Comments
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Attention
• • •
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Attention comments
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Orientation
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Orientation comments
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Memory deficits
• • •
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Memory comments
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Insight
• • •
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Insight comments
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Judgment
• • •
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Judgment comments
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ROS
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CONSTITUTIONAL
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Neuro
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HEENT
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CV
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Resp
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ENDO
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GI
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GU
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MSK
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Derm
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HEMAT
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HEPATIC/RENAL
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Lymph
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Allergies
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Breastfeeding?
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14+ pt. ROS otherwise negative
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Medical Records/Labs/Diagnostics reviewed
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ASSESSMENT
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Status of Progress
• • •
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DSM DIAGNOSES
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Suicide Assessment
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Suicide Risk Assessment
• • •
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Suicide risk factors
• • •
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Suicide protective factors
• • •
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PLAN
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Plan Interventions
• • •
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Medication Changes?
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Labs/Tests
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Referrals/Consultations
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Primary Care Provider
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Therapy
• • •
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Therapy Recommendations
• • •
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Therapy Comments
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4. Lifestyle recommendations
• • •
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Additional Lifestyle comments
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Next appointment
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Repeat every
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ROI for
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Coordination of Care
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Telehealth
• • •
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Time spent ___ min
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CPT Code/s
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Time spent reviewing diagnostic impressions, instructions for management, risks and benefits of treatment options, risk factor r
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Notes
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Lithium Lab Monitoring
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Depakote Lab Monitoring
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