Adult Outpatient Clinical

Psychiatry
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NOTE
[checkbox value="First encounter by student; Ongoing treatment by psychiatric provider; Outpatient Medication Managment; Routine followup|First encounter by student|Repeat encounter by student|Initial encounter by psychiatric provider|Ongoing treatment by psychiatric provider|in partial hospitalization program|in outpatient clinic|Routine followup|discharge planning|family meeting|observation only|shared approach|Student led"]
[checkbox value="Accompanied by "][checkbox value="Mother|Father|Grandmother|Grandfather|Case worker"]

REFERRAL
[checkbox value="Self|Therapist|Inpatient Psychiatric Unit|Primary Care Provider"] [checkbox value="for psychiatric medication managment|for psychiatric evaluation"]

CURRENT ENCOUNTER HX & CONTENT
[textarea rows="8"]
[checkbox value="Client: |Parent: |Grandparent: "][checkbox value="Primary complaint is "][textarea rows="1"][checkbox value=" which is "][checkbox value="better.|worse.|same.|new."][checkbox value=" Exacerbating factors include "][text size="10"][checkbox value=" Alleviating factors include "][text size="10"][checkbox value=" with good effect. | with fair effect. | with minimal effect. "][checkbox value="Client:|Parent:|Grandparent:"][checkbox value=" Primary complaint is described as being "][checkbox value="tolerable.|intrusive.|debilitating.|mild."]

[checkbox value="Client: |Parent: |Grandparent :"][checkbox value="Alternative complaint is "][textarea rows="1"][checkbox value=" which is "][checkbox value="better.|worse.|same.|new."] [checkbox value="Exacerbating factors include "] [text size="10"][checkbox value=" Alleviating factors include "][text size="10"][checkbox value=" with good effect. | with fair effect. | with minimal effect. "][checkbox value="Client:|Parent:|Grandparent:"][checkbox value=" Alterntive complaint is described as being "][checkbox value="tolerable.|intrusive.|debilitating.|mild."]

[checkbox value="Client: |Parent: |Grandparent: "][checkbox value="Current opinion of medications is that "][checkbox value="they are working|they are not working|they cannot tell if they are working|they are making things worse|and they would like them to be adjusted. |and they would like them continued. |and they would like them to be stopped. |and they are uncertain if they should continue taking them. "] [textarea rows"1"][checkbox value="Patient's current attitude toward taking medications is "][checkbox value="enthusiastic.|cooperative|adherant.|agreeable.|oppositional.|ambivalent.|apathetic.|indifferent."] [checkbox value=" Medication adherence has been "][checkbox value="good|fair|poor|due to patient frequently forgetting doses|due to patient refusing to take medications|and patient is independent in taking medications.|and patient requires a significant amount of support from caregiver."] [textarea rows"1"]

[checkbox value="Patient denies "][checkbox value="Suicidal ideation|Homicidal ideation|Self-harm thoughts|Auditory Hallucinations|Visual Hallucinations|Tactile Hallucinations|Difficulty with sleep|Difficulty with appetite|Mood Instability|Adverse effects of medications|Pain/physical complaints"]
[checkbox value="Patient reports positive for "][checkbox value="suicidal ideation|homicidal ideation|self-harm thoughts|auditory hallucinations|visual hallucinations|tactile hallucinations|difficulty with sleep|difficulty with appetite|mood instability|adverse effects of medications|pain/physical complaints"]
Affect is [checkbox value="flat|blunted|constricted|labile|bright"]
Mood is [checkbox value="anxious|dysphoric|depressed|irritable|tearful|sad|agitated|fearful|euthymic|euphoric"]
Thought process presents as [checkbox value="reality based|disorganized|circumstantial|tangential|flight of ideas|loose association|perseverative|thought blocking|ideas of reference|grandiose|paranoid|persecutory|religious|somatic|self accusatory"]
Speech is [checkbox value="regular rate and rhythm|rapid|slow|rambling|slurred|monotone|pressured|laconic"]
Gait is [checkbox value="regular|irregular|shuffling|unsteady"]
[checkbox value="No observed "][checkbox value="psycho-motor agitation|internal preoccupation|response to internal stimuli"]
[checkbox value="Patient displays "][checkbox value="internal preoccupation|response to internal stimuli|psychomotor agitation|difficulty following simple tasks|difficiulty responding to questions|difficulty with cognitive processing|difficulty participating in interview/therapy process"]

PAST PSYCH HX
[textarea rows="8"]
Substance/s misuse: [checkbox value="None|Unable to obtain as student|No additions, deletions, or revisions|Cannabis|Heroin|Prescription Pain medication|Stimulants|Hallucinogens|Cocaine|Alcohol|Tobacco|Caffeine"] [textarea rows="1"]
Past psychiatric diagnoses: [checkbox value="None|Unable to obtain as student|No additions, deletions, or revisions|Depression|Anxiety|ADHD|OCD|PTSD|Oppositional Defiant Disorder|Autism Spectrum Disorder|Bipolar Disorder I|Bipolar Disorder II|Schizophrenia|Schizoaffective disorder|Borderline Personality Disorder|Antisocial Personality Disorder|Mood Disorder"] [textarea rows="1"]
Abuse/Trauma: [checkbox value="None|Unable to obtain as student|No additions, deletions, or revisions|Verbal/Physical abuse as child|sexual abuse|witnessing domestic violence|neglect|bullying|domestic violence|assault|death of a loved one"]
Violence:[checkbox value="None|Unable to obtain as student|No additions, deletions, or revisions|assaultive to siblings|assaultive to parents|assaultive to staff|unprovoked|as a result of limit setting|when psychotic|resulting in significant injury of victim"]
Legal History/issues: [checkbox value="None|Unable to obtain as student|No additions, deletions, or revisions|assault charges|protection from abuse order|DHHS involvement|pending court date|probation|to be released into police custody after completion of treatment"]
Suicide/homicide attempts/gestures: [checkbox value="None|Unable to obtain as student|No additions, deletions, or revisions|overdose|hanging|cutting|walking into traffic|jumping off bridge|threatened life of others"] [textarea rows="1"]
Prior Treatment or Therapy inpatient/outpatient: [checkbox value="None|Unable to obtain as student|No additions, deletions, or revisions|One inpatinet psychiatric hospitalization|multiple inpatient psychiatric hospitalizations|long term state hospital admissions|short term inpatient hospitalizations|crisis unit stays|partial hospitalization program|outpatient psychiatry|outpatient therapy|case management|community support worker|behavior plan in school|school counselor|primary care provider|dental"] [textarea rows="1"]

Family/Significant other/social connectedness - family of origin -
[checkbox value="Unable to obtain as student|No additions, deletions, or revisions"] [checkbox value="Patient lives"] [checkbox value="Alone|not in contact with known family.|With parent/s.|with parent/s and sibling/s.|with other family members.|with foster family.|with significant other.|in grouphome."]
[checkbox value="Has a guardian who is "][checkbox value="Mother.|Father.|Grandparent.|DHHS worker."][checkbox value=" Has payee."]
[checkbox value="Maternal history of: "][checkbox value="alcohol use|opiate use|polysubstance use|depression|anxiety|bipolar disorder|schizophrenia|violence|suicide attempts|completed suicide"][checkbox value="Paternal history of: "][checkbox value="alcohol use|opiate use|polysubstance use|depression|anxiety|bipolar disorder|schizophrenia|violence|suicide attempts|completed suicide"][checkbox value="Sibling history of: "][checkbox value="alcohol use|opiate use|polysubstance use|depression|anxiety|bipolar disorder|schizophrenia|violence|suicide attempts|completed suicide"]

Hobbies/Acitivities/Habits/Occupation
[checkbox value="No additions, deletions, or revisions|Unable to obtain as student|school|video games|spending time with friends|sports|art|reading|writing|swimming"][textarea rows="2"]

PAST/CURRENT MED HX
[textarea rows="2"][checkbox value="Unremarkable|Unable to obtain as student|No additions, deletions, or revisions|Cardiovascular history:|Chest pain/angina|CHF|HTN|Hyperlipidemia|cardiac surgeries|DVT||Respiratory history:|asthma|COPD|bronchitis|sleep apnea||Communicable Disease:|Hep A|Hep B|Hep C|HIV/AIDS|TB||Neurological History:|Chronic Pain|Head Injury|Seizure Disorder|Migraine|Chronic headache||Medical Device History:|Bipap/CPAP|Oxygen|Pacemaker|Insulin Pump|Cane|Walker|Dentures|Glasses||Musculoskeletal history:|arthritis|amputation|back/neck problems|congenital abnormalities|fibromyalgia|osteoporosis|metal implants|Endocrine/Metabolic|Diabetes-insulin dependent|diabetes-non-insulin dependent|hypothyroid||Integumentary:|Ulcers|eczema|psoriasis|skin breakdown related to:||EENT history:|ear problems|eye problems|nasal/sinus problems||Sexual/Reproductie history:|Abnormal bleeding/discharge|birth control|menopause|sexually active|sexually transmitted disease|recent pregnancy|currently pregnant"]

LAB WORK:
[checkbox value="Unremarkable|None|Unable to obtain as student|No additions, deletions, or revisions"] [checkbox value="Lithium level:"] [textarea memo="0.8-1.2 mEq/L" rows="1"] [checkbox value="Depakote Level:"] [textarea memo="50-110 mcg/mL" rows="1"] [checkbox value="Tegretol Level:"] [textarea memo="5-12 mcg/mL" rows="1"] [checkbox value="Clozapine Level:"] [textarea memo="250-350 ng/mL" rows="1"] [checkbox value="H A1c:"] [textarea memo=">5.7%. 5.7-6.4 = prediabetes" rows="1"] [checkbox value="EKG QTC:"] [textarea memo="360-440 ms" rows="1"] [checkbox value="Ammonia Level:"] [textarea memo="Adults 9.5-49 mcg/dL Child 40-80 mcg/dL" rows="1"] [checkbox value="Prolactin Level:"] [textarea memo="male 2-18ng/mL. female 2-29 ng/mL. pregnant women 10-209ng/mL" rows="1"]

RX HX:
[textarea rows="4"][checkbox value="None|Unable to obtain as student|No additions, deletions, or revisions"]


Current RX:
[checkbox value="None|No additions, deletions, or revisions"][textarea rows="8"]

DSM - 5 (ICD - 10 Code) Diagnositics:
The Following are based on currently available info and may be changed as additional info becomes available
[checkbox value="No additions, deletions, or revisions"][textarea rows="8"]

Applicable Z Codes
[textarea rows="8"]

ENCOUNTER THERAPEUTIC & MEDICAL/MEDICATION MANAGEMENT INTERVENTIONS
Instruments/screening tools, results, & meaning:[checkbox value="N/A"][textarea rows="1"]
Particular psychotherapeutic strategies used: Person centered therapy, unconditional positive regard, active listening, reflection of feeling[checkbox value=", CBT|use of positive coping mechanisms|reinforced current use of positive coping mechanisms|suggestions of positive coping mechanisms|encouraged self observation"].[textarea rows="1"]
Particular medical/medication management strategies:[checkbox value=" Continue home medications as prescribed. "][textarea rows="1"]
Particular psychoeducative strategies: [checkbox value="N/A"][checkbox value="medication education for "][textarea rows="1"] [checkbox value="Sleep hygiene|smoking cessation|disease progression|diagnosis education|utilization of community resources|self-advocacy|risks of substance use|substance use abstinence|dietary considerations"] [textarea rows="1"]

DISPOSITION, INSTRUCTIONS, RECOMMENDATIONS, PLAN
[checkbox value="Plan for followup appointment in "][checkbox value="2 weeks|4 weeks|6 weeks|2-3 months"][checkbox value=" for followup on medication changes.| for continuing medication management. "] [checkbox value="Plan to continue maximizing "][textarea rows="1"]

[checkbox value="Ordered: "][checkbox value="EKG|CBC with diff|Lipid profile|HA1C|Lithium level|Tegretol Level|Depakote Level|Clozaril level|Prolactin|Urine Preg|Urine Drug"]

OWN OBSERVATIONS/IMPRESSIONS
Patient appears [checkbox value="cooperative|anxious|irritable|disengaged|ambivalent|appathetic|oppositional|in denial|engaged|invested|enthusiastic|optimistic"] with regard to mental health disorder and current treatment.[checkbox value=" Patient's family provides the majority of the insight into the chief complaint."][checkbox value=" The majority of the complaints appear to be situational|and they do not seem to be likely to adjust circumstance.|and they seem to be motivated to make psychosocial adjustments.|and they are actively working to improve current situation."][checkbox value=" The client is clearly displaying signs and symptoms of diagnosis as evidenced by "][textarea rows="1"][checkbox value=" I question the diagnosis of "][text size="10"][checkbox value=" due to the patient presenting with "][text size="10"][checkbox value=" and think that a more appropriate diagnosis might be "][text size="10"][checkbox value=" I feel a more appropriate medication change would have been "][text size"8"][checkbox value=" My overall impression of the patient's prognosis is "][checkbox value="good|fair|poor"][checkbox value=" if patient is able to continue with medication and therapy on a regular basis.| unless the patient becomes engaged in treatment| and will likely decompensate further for a significant amount of time before potentially becoming engaged in treatment."]
[textarea rows="8"]
NOTE



REFERRAL


CURRENT ENCOUNTER HX & CONTENT









Affect is
Mood is
Thought process presents as
Speech is
Gait is



PAST PSYCH HX

Substance/s misuse:
Past psychiatric diagnoses:
Abuse/Trauma:
Violence:
Legal History/issues:
Suicide/homicide attempts/gestures:
Prior Treatment or Therapy inpatient/outpatient:

Family/Significant other/social connectedness - family of origin -




Hobbies/Acitivities/Habits/Occupation


PAST/CURRENT MED HX


LAB WORK:
0.8-1.2 mEq/L 50-110 mcg/mL 5-12 mcg/mL 250-350 ng/mL >5.7%. 5.7-6.4 = prediabetes 360-440 ms Adults 9.5-49 mcg/dL Child 40-80 mcg/dL male 2-18ng/mL. female 2-29 ng/mL. pregnant women 10-209ng/mL

RX HX:



Current RX:


DSM - 5 (ICD - 10 Code) Diagnositics:
The Following are based on currently available info and may be changed as additional info becomes available


Applicable Z Codes


ENCOUNTER THERAPEUTIC & MEDICAL/MEDICATION MANAGEMENT INTERVENTIONS
Instruments/screening tools, results, & meaning:
Particular psychotherapeutic strategies used: Person centered therapy, unconditional positive regard, active listening, reflection of feeling .
Particular medical/medication management strategies:
Particular psychoeducative strategies:

DISPOSITION, INSTRUCTIONS, RECOMMENDATIONS, PLAN




OWN OBSERVATIONS/IMPRESSIONS
Patient appears with regard to mental health disorder and current treatment.
Result - Copy and paste this output:

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