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Plan Details:
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Medication Changes:
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Med Change Comments
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New Medication Rationale
• • •
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Continue Medication Rationale
• • •
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Taper Medication Rationale
• • •
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Laboratory Orders:
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Venous Puncture
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Fasting Lab:
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Labs
• • •
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Lab Comments
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MTL Molecular Testing
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Spravato Paperwork
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TMS Therapy
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Ketamine Assessment/or Set Up for Treatment
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Neurocognitive Testing:
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Referrals
• • •
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Referral Comments
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Release of information
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Read
• • •
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General Instructions
• • •
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Education
• • •
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Education Comments
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Diet
• • •
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Diet Comments
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GOALS:
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Follow-Up
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Total Time with Patient (Face-to-Face and Nonface-to-Face) Minutes:
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Time Spent with Patient Includes:
• • •
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Individual Therapy Time:
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SBIRT TIME-Only Charge if Positive
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Review of Testing:
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Continuity of Care
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Care Team:
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