|
Plan Details:
|
|
|
Medication Changes:
|
Med Change Comments
|
|
New Medication Rationale
• • •
|
Continue Medication Rationale
• • •
|
|
Taper Medication Rationale
• • •
|
|
|
Spravato Paperwork
|
esketamine (Spravato) Treatment
|
|
Ketamine Infusion
|
Neurocognitive Testing Scheduled
|
|
NeuroStar TMS Treatment
|
|
|
LAB ORDERS
|
|
|
Venous Puncture:
|
|
|
Labs
• • •
|
Lab Comments or other orders:
|
|
Molecular Pharmacogenetic Testing
|
Genomind Genetic Testing:
|
|
Methylcobalamin 5 mg/mL
|
Diphenhydramine HCl (Benadryl)
|
|
Referrals
• • •
|
Referral Comments
|
|
|
|
|
Release of information
|
|
|
Read
• • •
|
General Instructions
• • •
|
|
Education
• • •
|
Education Comments
|
|
Diet
• • •
|
Diet comments
|
|
Follow-Up
|
|
|
GOALS:
|
|
|
Total Time with Patient in Minutes: (non face-to-face and face-to-face)
|
|
|
Time Spent with patient included:
• • •
|
|
|
SBIRT Time (Only charge if positive):
|
|
|
Individual Therapy:
|
|
|
Review of Testing:
|
|
|
Continuity of Care
|
|
|
Care Team:
|
|
