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Reason For Encounter
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Referral Source
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Referred to clinic by hospital/provider/self
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Clinic Assignment
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Bridge Clinic / Provider Continuity Clinic / Clozapine Clinic
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Clinical One-Liner
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This is a [Age]-year-old [sex]...
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Chief Complaint
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In patient own words, use quotes
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History of Present Illness
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HPI
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Symptom first onset, duration, course. Severity and functional impact, precipitating and perpetuating factors. Current Stressors and attempts to treat self.
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Psychiatric Review of Symptoms
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Major Depression
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Pertinent positives and negatives. Sleep changes, appetite changes, excess guilt/worry, low energy, difficulty concentrating, psychomotor slowing, suicidal ideation. (Female patients screen PMDD).
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Mania
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Pertinent positives/negatives. Clearly differentiate NOW vs PAST symptoms. Decreased need for sleep, increase goal directed activity, distractible, labile mood, grandiosity, racing thoughts, talkativeness, excessive involvement activities.
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Psychosis
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Pertinent positives and negatives. Hallucinations (auditory, visual), delusional content, paranoia, thought/speech disorganization, alogia, asociality, avolition
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Anxiety
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Pertinent positives and negatives. Excessive worry in different life areas, muscle tension in neck/shoulders, panic attacks, specific phobias, social anxiety
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Obsessions/Compulsions
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Pertinent positives and negatives. Intrusive thoughts, urges to perform routines to relieve distress of intrusive thought, body image distortions, excessive mirror time, rituals.
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Eating Disorders
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Pertinent positives and negatives. Clearly differentiate CURRENT and PAST symptoms. Food restriction, purging, binging, excessive exercise.
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Trauma Screening
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Trauma Exposure?
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Trauma Related Symptoms?
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Optional History
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Realm of trauma (physical, sexual, military/police, emotional), as a child vs as adult, prior reports filed.
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PTSD Symptoms
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Pertinent positives and negatives. Differentiate acute vs post traumatic. Persistent thoughts of trauma, avoids specific activities/thoughts, negative emotions about self/world, arousal changes, sleep disturbance, nightmare hypervigilance.
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Borderline Personality Disorder Traits
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Fear of abandonment, unstable intense interpersonal relationships, identity disturbance, impulsive behaviors, unstable mood (in 1 day), chronic emptiness feeling, anger, stress-induced paranoia, parasuicidal behaviors and transient thought
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Past Psychiatric History
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Past Psychiatric History
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Diagnosed by psychiatry, PCP, self. Diagnosis year. Previous clinics, doctors, therapists, PCP prescribing antidepressants etc
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Medical History
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Medical History
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Short term but active medical problems and treatments (list short term medications here)
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Social and Developmental History
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Social History
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Social History
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Substance Use History
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Substance Use History
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Cigarettes (quantity, brand, PPD, started at age) tried to quit history.
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Objective
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Mental Status Examination
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Mental Status Exam
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Mental Status Exam
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Appearance
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Attitude and Behavior
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Psychomotor
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Speech
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Mood
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Affect (congruent, rating, quality, range)
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Thought Content
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Suicidal Ideation
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Homicidal ideation
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Thought Process
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Perceptual Disturbances
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Sensorium
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Cognition
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Impulse Control
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Insight
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Judgement
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Labs and Diagnostics
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Review/document clinically relevant labs and imaging
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Psychiatric Rating Scales
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If any, document validated psychiatric rating scales and scores
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Assessment
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Diagnostic Formulation
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Most likely primary diagnosis, with explanation of differential diagnosis considerations. Episode specification, severity.
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Biopsychosocial Formulation
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Biological Predispositions (genetic, medical comorbidities), Psychological Factors (trauma hx, personality, coping), Social Factors (support/stress network, work/school, financial/housing, cultural)
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Medical Decision Making
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Complexity, Data Reviewed, Risk Level
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Plan
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Treatment Plan
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Medications, Therapy, Labs
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Diagnostic Monitoring
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Diagnostic clarity approach, monitor for response to medications or substance cessation, waiting for labs, no changes
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Psychotropic Medications
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Psych Med Plan, prescriptions, med changes, interactions, reason for doses, INDICATIONS
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Lab Orders and Medical Problem Monitoring
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New Labs and Medical Problem Monitoring (antipsychotic metabolic labs)
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Valproic Acid Labs
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Lithium Labs
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Therapy
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Therapy Interventions such as continue psychotherapy with psychiatric provider, continue CBT or other prescribed therapy, any referrals
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Safety Plan
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Safety plan review.
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Level of Care
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Level of Care: Outpatient rationale, i.e. does not meet inpatient criteria or involuntary hold criteria.
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Additional Documentation for Billing Efficacy
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Patient Education and Shared Decision Making
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Shared decision making, explanation of timeline, prognosis.
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Medical Necessity of Office Visit
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Provided Supportive Therapy and Psychoeducation
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Provided Psychotherapy Intervention
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Client Response to Psychotherapy
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Provider Time Spent
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Additional Time Spent Reviewing Documentation
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Time Spent Reviewing Referral Packet, Provider Notes, Chart Review. Estimate 5-10 minutes. Document what notes were reviewed.
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Time Spent for Medication Management:
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99203 (1 problem/straightforward: 20-30 minutes). 99204 (2 problems or 1 chronic med/psych problem + 1 active psych problem) 22-32 minutes. BRIDGE Intakes are 99204 for safety assessments post hospitalization.
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Time Spent with Patient for Psychotherapy
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90833 (16-20 minutes)
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Clinic Follow-Up
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Follow-Up
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Return to clinic for follow up appointment in X days/weeks/months
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