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Medication Mangement/Psychotherapy Follow Up
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Telepsychiatry Note
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Date of initial consult or first appt with you :
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Date of Last Appointment
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Appointment Assessment Complemented or Completed With
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Reported by Other:
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Patient Quote:
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Subjective Hx:
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Accompanied By
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Other
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Any Changes to Medical History including Medications
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Comment if Changes
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Acute medical problems/complaints
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Comment if Changes
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Chronic medical problems
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Comment if Changes
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Patient Interview
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Appetite/Sleep/Somatic
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Appetite/Sleep/Somatic Summary
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The patient reports feeling:
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Summary:
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Labs/Vitals/Weight/Diagnositics:
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Labs:
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Labs (if abnormal, explain):
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Vitals:
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Vitals/Physical Status
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Weight
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Weight
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Diagnostics
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Diagnostics
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Review of Systems
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Review of Systems
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Constitutional
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Comment
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Eyes
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Comment
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ENMT
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Comment
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Respiratory
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Comment
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Cardiovascular
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Comment
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Gastrointestinal
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Comment
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Genitourinary
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Comment
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Musculoskeletal
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Comment
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Integumentary
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Comment
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Neurologic
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Comment
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Psychiatric
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Comment
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Review of Systems Comments
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Alcohol/ Illicit Drug Assessment
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Pt Denies Alcohol/Illicit Drug Use:
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If no, please specify substance, frequency, amount:
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Mental Status Exam
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Appearance:
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A & O:
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Eye Contact:
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Behavior:
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Speech:
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Affect:
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Thought Content
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Though Process:
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Cognition:
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Insight
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Judgement
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Impulse Control
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Attention/Concentration
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Memory
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Mood
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Mood/Cognition Subjective:
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SI:
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SI
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Contracts for Safety
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Contracts for Safety
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Homicidal Ideations
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Homicidal Ideations
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Psychosis
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Psychosis
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Auditory/Visual Hallucinations
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AuditoryVisual Hallucinations
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Risk Assessment
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Risk Assessment
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Suicide Risk Assessment
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Suicide Risk Factors
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Protective Factors:
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Protective Factors
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Attitude towards Examiner
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Diagnsotic Tools and Assessment
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PHQ-9
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PHQ-9 Score
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GAD-7
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GAD-7 Score
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MFQ
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MFQ Score
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GAD-2
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GAD-2 Score
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Other
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Finding/s
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Diagnostic Impression
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DI: Major Depressive Disorder
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DI: Psychotic Disorders
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DI: Other Disorders
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DI- Substance Use Disorders:
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DI- ADHD
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DI: Bipolar
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DI: Eating Disorders
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DI: Cognition
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DI: (If not listed as favorite above)
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Screening Tools used
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Progress/Assessment/E/M Assessment/Treatment Planning
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Therapeutic Intervention Used
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Problem List
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Pt Progressing with therapy:
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EVIDENCE OF PROGRESS OR NEW TX PLAN
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Therapy Treatment Plan
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Additional therapy plan details
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Psychotherapy Note
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Psychotherapy Narrative
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Psychotherapy Start Time:
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End Time (MUST MEET 90833/36 CPT CRITERIA):
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Current Medications Reviewed
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Date of medication adjustments
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Compliance
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Comments
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Medication Concerns per patient
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Comments
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Prn’s required
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Comments
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Any medication changes?
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Specify medication changes or addt'l Tx planning.
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Medication Treatment Plan:
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Prescription/s Sent
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Inpatient/Outpatient Treatment Program Discussed?
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If Inpatient/Outpatient Treatment was discussed, explain:
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Additional treatment recommendations:
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Follow Up:
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Patient/Family Education
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CPT
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Appointment Length
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PMPD Reviewed
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PMPD, comments
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Controlled Substance and Medication Education
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Risks/Benefits Statement
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ROI signed for
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Records Requested
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Supervisor of PMHNP
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Footer Information
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Patient Rights
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