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Clinical note
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Introduction and ID verification
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Chief Complaint (Patient's Own Words)
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HPI
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Patient Negatives
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HPI
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Current Psychiatric Medications
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Other Medications
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Previously prescribed psychiatric medications
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Vitamins & Supplements
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Allergies
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Psychiatric History, Previous or Current Therapy, Suicide Attempts, Hospitalizations
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Other Medical Problems
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Family Psychiatric History
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Family Medical History
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Surgical History
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Wakes Up Around
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Sleep Hygiene
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Work/School Status & Schedule
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Lives With:
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Tobacco Use
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Marijuana Use
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Alcohol Use
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Caffeine Use
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Suboxone/Methadone/Phentermine Use
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Additional Comments Related to Tobacco, Alcohol, Drug Use
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Exercise
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Diet & Nutrition (special plans, meal frequency, content)
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Water Intake
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Social - Interests, Hobbies, Life Events
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MENTAL STATUS EXAM
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Appearance & Behavior : Appears Alert, Cooperative, And Well - Kempt
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Appearance & Behavior
• • •
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Appearance & Behavior
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Psychomotor: Within Normal Rage With Minimal Fidgeting & Few Postural Shifts
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Psychomotor
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Psychomotor
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Speech - Normal Rate, Tone, And Flow
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Speech
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Speech
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Attention: Within Normal Rage With Little Or No Need to Redirect
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Attention
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Attention
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Emotion (Mood & Affect) - Affect & Mood Are Congruent, Mood Is Euthymic, Affect Shows Full Range
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Emotion (Mood & Affect)
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Emotion (Mood & Affect)
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Perception (Auditory/Visual Hallucination)
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Perception (Auditory/Visual Hallucination)
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Perception (Auditory/Visual Hallucination)
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Thought Content (Suicidal/Homicidal Ideation) and Thought Process
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Thought Content (Suicidal/Homicidal Ideation) and Thought Process
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Thought Content (Suicidal/Homicidal Ideation) and Thought Process
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Suicidal/Homicidal Ideation
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Suicidal Ideation Commentary
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Insight & Judgment - Appears to have good insight & good Judgment.
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Insight & Judgment
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Insight & Judgment
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Cognition - A&O x 3; Normal Intellect
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Cognition
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Cognition
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Mental Staus Exam Additional Comments
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Vitals
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Vitals Comments
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ASSESSMENT: After Reviewing The Assessment Done by Psychologist, Discussing Patient's Symptoms, Patient Presents with Sympt
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ASSESSMENT Comments
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Diagnosis/ICD Code
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Other Diagnosis/ICD Code
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PLAN: Patient Can Benefit From Medication. Informed Consent Was Obtained From The Patient. Medication List Was Reconciled. Risk
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PLAN Comments
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1.Will e-prescribe ______ to patient’s preferred pharmacy.
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2. PDMP website reviewed and no inconsistencies noted.
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PDMP Inconsistencies
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3. If any severe side effects develop such as fainting, chest pain, shortness of breath, or thoughts of self-harm.
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4. Patient instructed to notify us if intolerable side effects develop such as: irritability, agitation, ongoing nausea/vomiting
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5. I recommend eating well-balanced meals and getting regular aerobic exercise (like 4-5x/week for 30 min. each time). Continue
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6. Therapy Recommendation
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7. Serotonin Syndrome Risk Caution
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8. For females: This medication is not safe to take if you are currently pregnant, trying to get pregnant or breastfeeding. If t
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9. Check HR, BP, and weight prior to next appointment.
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10. Patient instructed to keep primary care doctor informed of medication changes.
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11. Patient instructed to follow up with me in 1 month for re-evaluation (sooner if needed)
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