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Clinical note
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Last Visit ASRS score
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Last Visit GAD-7 score
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Last Visit PHQ-9 score
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Introduction and ID verification
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Date of Last Appointment
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Time interval since last appointment
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Other time interval since last appointment
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Current prescribed medications from what provider including strength, formulation & timing
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Side Effects
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Side Effects Comments
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PDMP Filled/Sold Dates Since Last Visit
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Medication Change Since Last Visit
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Clinical Change since Last Visit
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Currently Seeing Therapist And/Or Health Coach
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FOR THE FOLLOWING FIELDS LISTED BELOW, PLEASE NOTE ANY CLINICALLY RELEVANT CHANGES SINCE LAST VISIT
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Vitamins / Supplements
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Allergies
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Wakes up around
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Sleep Hygiene
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Work/School Staus & Schedule
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Lives With
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Tobacco/Alcohol/Drug Use
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Caffeine Intake
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Water Intake
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Diet/Nutrition
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Exercise
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Social - Interests, Hobbies, Life Events
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Mental Staus 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)
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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: Well-Controlled Diagnoses
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Well-Controlled Diagnoses
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ASSESSMENT: Suboptimal Diagnoses
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Suboptimal Diagnoses
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ASSESSMENT: Uncontrolled Diagnoses
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Uncontrolled Diagnoses
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PLAN
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Prescription Medications Provider is E-Prescribing
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30 Day Medication Management Follow Up Appointment
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60 Day Med Mgmt F/U Appt
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Alt Interval Med Mgmt F/U
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Alt Interval Med Mgmt F/U - RX Preference
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90 Day Med Mgmt F/U - Future Tasks
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90 Day Med Mgmt F/U - 90 Day Fill
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90 Day Med Mgmt F/U - Postdated Scripts
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RX Outreach First Time Use
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1. Infored consent obtained from the patient. Medications reconciled. Risk, Benefits, Side Effects, And Alternatives Discusses
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2. PDMP Website Reviewed and No Inconsistencies Noted.
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PDMP Inconsistencies
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3. Call 911 And Stop Prescribed Medication If Any Sever Side Effects Develop Such As Fainting, Chest Pain.
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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 & Getting Regular Aerobic Exercise (Like 4-5/week for 30min 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.
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9. Check HR, BP, And Weigh Prior To Next Appointment.
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10. Patient Instructed To Keep Primary Care Doctor Informed Of Medication changes.
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