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Chief Complaint
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Chief Complaint
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History of Present Illness
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HPI
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Past Psychiatry History
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Psychiatric History - Endorsed
• • •
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Psychiatric History - Denied
• • •
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Psychiatric History Comment
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Psychiatric Hospitalizations
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Suicide Attempts
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NSSIB
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Psychiatric Medication Trials
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Medical History
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Past Medical History
• • •
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Past Medical History Comment
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Surgeries
• • •
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Past Surgeries Comment
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Childhood Illnesses
• • •
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Childhood Illnesses Comment
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Current Medications
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Medications
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Allergies
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Allergies
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Substance Use History
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Caffeine
• • •
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Caffeine Comment
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Tobacco
• • •
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Tobacco Comment
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Alcohol
• • •
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Alcohol Comment
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Drug
• • •
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Pattern of Drug Use
• • •
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Drugs Comment
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Family History
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No family psychiatric history
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Father Psychiatric History
• • •
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Father Comments
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Mother Psychiatric History
• • •
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Mother Comment
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Siblings Psychiatric History
• • •
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Siblings Comment
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Other Family Psychiatric History
• • •
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Other Family Comment
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Social History
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Schooling
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Work History
• • •
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Relationship
• • •
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Psychosexual
• • •
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No. of Children
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Children: Name, Age
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Step-Children
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Single Parent
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Currently Resides With
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Hobbies/ Activities
• • •
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Military History
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Physical Trauma
• • •
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Physical Trauma Comments
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Childhood Trauma
• • •
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Childhood trauma comment
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Legal History
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Legal history comment
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Medical Review of Systems
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General [-]
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General
• • •
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Skin [-]
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Skin
• • •
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HEENT [-]
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HEENT
• • •
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Cardiovascular [-]
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Cardiovascular
• • •
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Respiratory [-]
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Respiratory
• • •
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GI [-]
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GI
• • •
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GU/Sexual [-]
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GU/Sexual
• • •
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MSK [-]
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MSK
• • •
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Neurological [-]
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Neurological
• • •
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Endocrine [-]
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Endocrine
• • •
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Psychiatric Review of Systems
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Depression [-]
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Depression
• • •
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Anxiety [-]
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Anxiety
• • •
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Mania [-]
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Bipolar
• • •
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Attention/Concentration: [-]
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ADHD
• • •
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OCD Spectrum [-]
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OCD
• • •
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Trauma/PTSD [-]
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PTSD
• • •
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Psychosis [-]
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Psychosis
• • •
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Disordered Eating [-]
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Disordered Eating
• • •
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ODD/Conduct/Antisocial [-]
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ODD/Conduct/Antisocial
• • •
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Borderline Personality Disorder [-]
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Borderline Personality
• • •
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Narcissistic Personality Disorder [-]
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Narcissistic Personality
• • •
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Suicidal/Homicidal [-]
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Suicidal/Homicidal
• • •
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Mental Status Examination
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Appearance
• • •
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Behavior/Attitude
• • •
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Speech
• • •
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Thought Process
• • •
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Thought Content
• • •
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Mood
• • •
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Affect
• • •
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Memory
• • •
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Concentration
• • •
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Insight
• • •
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Judgment
• • •
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Measures
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PHQ9 - Depression
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PHQ-9 Score
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GAD7 - Anxiety
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GAD-7 Score
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Y-BOCS - Obsessions/Compulsions
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Y-BOCS Score
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ASRS - ADHD Self-Report
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ASRS Score
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PCL5 - Trauma/PTSD
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PCL-5 Score
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BPQ - Borderline Personality Disorder
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BPQ Score
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MDQ - Mood Disorders
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MDQ Score
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Psychiatric Impression
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Psychiatric Impression
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Risk Assessment
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Presence of suicidal thoughts
• • •
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Acute and Dynamic Risk Factors
• • •
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Static Risk Factors
• • •
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Protective Factors
• • •
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Suicide Risk Level
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Treatment changes made for moderate or high risk
• • •
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Comments
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Psychotherapy
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Psychotherapy
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Therapeutic Intervention Used
• • •
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Problem List
• • •
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Descriptive Therapeutic Technique Used
• • •
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Other Problems (not listed):
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Targeted Goals:
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Pt Progressing with therapy:
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EVIDENCE OF PROGRESS OR NOT
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Therapy treatment plan:
• • •
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Homework Assignments:
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Additional treatment plans:
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Follow Up:
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Psychotherapy Start Time:
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End Time:
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CPT
• • •
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Risks/Benefits Statement
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