|
CPT code(s):
|
Time:
|
|
Information from:
• • •
|
|
|
Telehealth
|
|
|
PMP
|
|
|
Emotional problems duration
|
pt's emo/bx prob have (change and sev)
• • •
|
|
Neg/pos factors
|
Contributing factor(s) comments
|
|
Interim PFSH
|
|
|
ROS
|
|
|
Other Psychiatric Treatment
|
|
|
Substance use:
|
|
|
Medical History
|
Changes to non-psych rx and med hx
|
|
Changes to non-psych rx and med hx
|
Bloodwork
|
|
Psychotherapy/Coor of care/Data
|
|
|
Face to face time
|
Type of therapy
• • •
|
|
Issues discussed
|
Data: past evaluations/records/bloodwork
|
|
> 50% counseling/coordination of care
|
|
|
Problem
|
Problem change and severity
• • •
|
|
Comments
|
No change
• • •
|
|
Problem
|
Problem change and severity
• • •
|
|
Comments
|
No change
• • •
|
|
Problem
|
Problem change and severity
• • •
|
|
Comments
|
No change
• • •
|
|
Problem
|
Problem change and severity
• • •
|
|
Comments
|
No change
• • •
|
|
Problem
|
Problem change and severity
• • •
|
|
Comments
|
No change
• • •
|
|
Problem
|
Problem change and severity
• • •
|
|
Comments
|
No change
• • •
|
|
Problem
|
Problem change and severity
• • •
|
|
Comments
|
No change
• • •
|
|
Depression qualities
• • •
|
Dep change and severity
• • •
|
|
Comments
|
|
|
General Anxiety
• • •
|
General anxiety change and severity
• • •
|
|
Comments
|
|
|
Phobia(s)
• • •
|
Phobia change and severity
• • •
|
|
Comments
|
|
|
Panic attacks
• • •
|
Panic attacks change and severity
• • •
|
|
Comments
|
|
|
Insomnia qualities
• • •
|
Insomnia change and severity
• • •
|
|
Comments
|
|
|
ADHD qualities
• • •
|
ADHD change and severity
• • •
|
|
Comments
|
|
|
Conduct/Oppositional behaviors:
• • •
|
ODD/CD severity and change
• • •
|
|
Comments
|
|
|
Other problem
|
Other problem change and severity
• • •
|
|
Comments
|
|
|
Mania qualities
• • •
|
Mania change and severity
• • •
|
|
Comments
|
|
|
PTSD
• • •
|
PTSD change and severity
• • •
|
|
Comments
|
|
|
OCD
• • •
|
OCD change and severity
• • •
|
|
Comments
|
|
|
Eating Disorder qualities
• • •
|
Eating d/o change and severity
• • •
|
|
Eating D/o comments
|
|
|
ASD qualities
• • •
|
ASD change and severity
• • •
|
|
ASD comments
|
|
|
Gender/sexual orientation qualities
• • •
|
Gender/sex change and severity
• • •
|
|
Gender/sex comments
|
|
|
Other stress/modifying factors:
• • •
|
Comments
|
|
Associated signs and symptoms
|
|
|
Depression neg
|
Anxiety neg
|
|
Insomnia neg
|
Mania neg
|
|
Psychosis neg
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Adult: no use
|
Adult: no use
• • •
|
|
Youth: no use
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PFSH
|
|
|
Developmental history:
|
|
|
Educational history:
|
|
|
Criminal history
|
|
