DEMOGRAPHIC DATA Patient’s age and patient’s gender identity IT MUST BE HIPAA compliant. SUBJECTIVE

DEMOGRAPHIC DATA

• Patient’s age and patient’s gender identity
• IT MUST BE HIPAA compliant.

SUBJECTIVE

• Chief Complaint (CC):
  • Place the patient’s CC complaint in Quotes
• History of Present Illness (HPI):
  • Reason for an appointment today.
  • The events that led to hospitalization or clinic visits today.
  • Include symptoms, relieving factors, and past compliance or non-compliance with medications
  • Any adverse effects from past medication use
  • Sleep patterns – number of hours of sleep per day, early wakefulness, inability to initiate sleep, inability to stay asleep, etc.
  • Suicide or homicide thoughts present
  • Any self-care or Activity of Daily Living (ADL) such as eating, drinking liquids, self-care deficits, or issues noted?
  • Presence/description of psychosis (if psychosis, command or non-command)
• Past Psychiatric History (PSH):
  • Past psychiatric diagnoses
  • Past hospitalizations
  • Past psychiatric medications use
  • Any non-compliance issues in the past?
  • Any meds that didn’t work for this patient?
• Family History of Psychiatric Conditions or Diagnoses:
  • Mother/father, siblings, grandparents, or direct relatives
• Social History: 
  • Include nutrition, exercise, substance use (details of use), sexual history/preference, occupation (type), highest school achievement, financial problems, legal issues, children, and history of personal abuse (including sexual, emotional, or physical).
• Allergies:
  • To medications, foods, chemicals, and others.
• Review of Systems (ROS) (Physical Complaints):
  • Any physical complaints by the body system? (Respiratory, Cardiac, Renal, etc.)

OBJECTIVE

• Mental Status Exam:
  • This is not a physical exam.
  • Mental Status Exam (MSE)

ASSESSMENT (DIAGNOSIS)

• Differentials
  • Two (2) differential diagnoses with ICD-10 codes.
  • Must include rationale using DSM-5 Criteria (Required)
  • Why didn’t you pick these as a major diagnosis?
• Working Diagnosis
  • Final or working diagnosis (1), with ICD-10 code.
  • Must include rationale using DSM-5 criteria required – Which symptoms/signs in the DSM-5 the patient matches mostly)

Plan

• Treatment Plan (Tx Plan):
  • Pharmacologic: Include complete information for each medication(s) prescribed
  • Refill Provided: Include complete information for each medication(s) refilled
• Patient Education:
  • Including specific medication teaching points
  • Was the risk versus benefit of the current treatment plan addressed for meds or treatment
  • Risk versus benefit of non-FDA approved for working diagnosis – Off-label use of medication education to patient addressed?
• Prognosis:
  • Make Decision for prognosis: Good, Fair, Poor
  • Provide brief statement lending support for or against the decided prognosis.
• Therapy Recommendations:
  • Type(s) of therapy recommended.
• Referral/Follow-up:
  • Did you recommend follow-up with a Psychiatrist, PCP, or other specialist or healthcare professionals?
  • When is the subsequent follow-up?
  • Include the rationale for the F/U recommendation or referral.

Reference(s):

• Include American Psychological Association (APA) formatted references.
• Include a reference from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) or the accompanying Desk Reference of Diagnostic Criteria from DSM-5.