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.