Cadet Summer Training Psych Note

HISTORY OF PRESENTING PROBLEM[conditional field="A" condition="(A).is('Followup')"][comment memo="
99212 requires 1 HPI
99213 requires 1 HPI + pertinent ROS
99214 requires 4 HPI + pertinent ROS plus one other + 1 P/F/S hx
99215 requires 4 HPI + complete ROS + 2 P/F/S hx"][/conditional][conditional field="A" condition="(A).is('Intake')"][comment memo="
Intake = 90792"][/conditional]
[conditional field="A" condition="(A).is('Intake')"][/conditional]
*Chief Complaint*
Intake performed by SPC Rose Leon, psychiatric technician on [date default="today"] at [text size="8"]
Patient is see in this [checkbox name="A" value="Intake|Followup"][checkbox name="b" value=" with psychotherapy"] for [checkbox value="depression|anxiety|psychosis|substance abuse|cognitive impairment|impulsivity|mood lability|sleep disturbance|alcohol dependence|opiate dependence|autism spectrum disorder"] [textarea memo="other" default="" rows="1"]
[textarea memo="*QUOTES* *REQUIRED*" default="" rows="8"]

*Interval History*
Patient presents as [comment memo="SYMPTOM"][checkbox value="depressed|anxious|aggressive|impulsive|inattentive|irritable|withdrawn|unable to sleep|delusional|auditory hallucinations|visual hallucinations"] [textarea memo="other" default="" rows="1"]
Which is described as[comment memo="SEVERITY "][checkbox value=" the same as it has been| better| somewhat worse than it has been| significantly worse than it has been"] [textarea memo="other" default="" rows="1"]
It seems to [checkbox value="be very brief in duration|last for awhile then goes away|always be present"]
The patient notices that it is sometimes improved by [comment memo="Modifying factors "][checkbox value="talking to someone|being alone|doing something physical like walking|doing something that is distracting"] [textarea memo="other" default="" rows="1"]
[conditional field="A" condition="(A).is('Intake')"]
History of Presenting Illness:
[textarea rows="6"]

Current Psychiatric Medications: 
[textarea rows="4"]

Currently in Therapy: 
[select value="denied|currently in "] [textarea rows="1"]

Current Suicidal Ideation: 
[select value="denied|yes with no plan|yes with a plan|not suicide but thoughts of being better off dead"][checkbox value="contracts for safety|cannot contract for safety"] [textarea rows="1"]

Guns in the home / access to guns: 
[select value="denied|yes "][textarea rows="1"][checkbox value=" Explained that we ask this question because guns in the home increase the risk of suicide, homicide and accidental death, Provided education about the importance of keeping guns locked and separated from ammunition. Explained that should this provider feel that patient is unsafe to self or others, provider and patient will work together to develop a safe place to keep weapons to decrease risk of impulsive suicide or homicide"][/conditional]

Mental Status Examination:
General: [select name="variable_2" value="alert and oriented in all spheres|obtunded|disoriented"].
Appearance: [select name="variable_3" value="well kempt|poorly kempt|appropriately dressed|inappropriately dressed|appropriately groomed|inappropriately groomed"].
Behavior - general: [select name="variable_4" value="in no acute distress|in acute psychological distress"].
Behavior - stability: [select name="variable_5" value="calm|agitated"].
Behavior - interactivity: [select name="variable_6" value="warm with comments and behavior|interactive|withdrawn"].
Behavior - eye contact: [select name="variable_7" value="eye contact good|eye contact fair|eye contact avoidant"].
Mood/Affect - stated: [select name="variable_8" value="normal|upbeat|euthymic|depressed"].
Mood/Affect - emotional range: [select name="variable_9" value="normal|broad|restricted"].
Mood/Affect - intensity: [select name="variable_10" value="normal|expansive|blunted|flat"].
Mood/Affect - congruence: [select name="variable_11" value="mood is congruent with affect|mood and affect are not congruent"].
Thought form and content: [select name="variable_12" value="normal|future oriented|logical, linear and goal-oriented|past oriented and somber|goal directed|scattered|hopeful|remorseful|enthusiastic|resigned"]
Attention: [select name="variable_13" value="no difficulty with attention or concentration|had some attentional and concentration problems during the exam"].
Perception - insight: [select name="variable_14" value="normal insight|poor insight"]
Perception - general: [select name="variable_15" value=normal|normal - denied any preoccupations, obsessions, delusions, hallucinations or perceptual disturbances"]
Cognition/Memory: [select name="variable_16" value="normal|grossly intact|below average|above average"].
Cognition/Memory - abstraction: [select name="variable_17" value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"]
Judgment: [select name="variable_18" value="normal|poor|good"].
Suicide/Assault: [select name="variable_19" value="no current or past ideation or intent|denies an active sense of wanting to harm self or others|present but without intent or plan|resolved"].
Patient is currently assessed to be at [select name="variable_20" value="low|moderate|high"] risk for self harm or harm to others as evidenced by ideation and behavior on today's exam.

Scales and Screening:
PHQ-9: [select value="unable to assess|declined|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
GAD-7: [select value="unable to assess|declined|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"][conditional field="A" condition="(A).is('Intake')"]
MDQ: [select value="negative|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
HITS:[select value="negative|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
PC-PTSD:[select value="negative|unable to assess|declined|1|2|3|4"]
AUDIT:[select value="negative|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
DAST-10:[select value="negative|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
SLUMS:[select value="N/A|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
[/conditional]
*Review of Systems* [conditional field="A" condition="(A).is('Followup')"][comment memo="Include for 99213 thru 99215"][/conditional]
The patient identifies the following symptoms: [comment memo="Pertinent System "][checkbox value="irritability|mood instability|heightened anxiety|attention problems|troubled by hallucinations|fearfulness|nightmares|alcohol cravings|opiate cravings"] [textarea memo="other" default="" rows="1"]
Other systems:
Neurological - [checkbox value="Headaches|weakness|disturbed sleep|denied"] [textarea memo="other" default="" rows="1"]
GI - [checkbox value="Upset stomach|nausea|constipation|heatburn|denied"] [textarea memo="other" default="" rows="1"].
All other systems negative

*Past/Family/Social History* [conditional field="A" condition="(A).is('Followup')"][comment memo="Include for 99214 + 99215
Consider Substance use, Social/Family Supports, Current medication, Housing, Financial, Legal"]
[textarea rows="3"][/conditional]

[conditional field="A" condition="(A).is('Intake')"]
Current Substance Use: 
[select value="Denied|N/A|Reports positive for "][checkbox value="alcohol|tobacco|cannabis|opiate use|methamphetamine use"] [textarea rows="1"]

Social Supports:
[checkbox value="none|significant other|extended family|children|friends|church members"][textarea rows="1"]

Marital status: 
[select value="married|partnered|single|"][textarea rows="1"]

Children: 
[select value="0|1|2|3|4|5|6|7|"][textarea rows="1"]

Lives: 
[select value="with significant other|alone|with children|with extended family|with parents|"][textarea rows="1"]

Works: 
[select value="on disability|retired|unemployed|works as a |"][textarea rows="1"]

Financial Concerns:
[select value="none|related to healthcare costs|related to supporting family|"][textarea rows="1"]

Source of Income: 
[select value="disability|social security|unemployment|work|family support|"][textarea rows="1"]

Housing Concerns:
[select value="none|unstable housing situation related to |"][textarea rows="1"]

Spirituality:
[select value="Christian|Catholic|Muslim|Jewish|Spiritual but not practicing|Athiest|Agnostic|"][textarea rows="1"]

Sexual Orientation:
[select value="heterosexual|homosexual|bisexual|declined to answer|unable to assess due to symptomatic presentation|"][textarea rows="1"]

Military:
[select value="denied|retired |active |"][textarea rows="1"]

Legal Concerns:
[select value="denied|reports positive for "][textarea rows="1"] 
HISTORIES:
[comment memo="All Information below is historical and not to be counted as part of the progress note"]
Previous Psychiatric Medications:
[textarea rows="1"]

Previous Psychiatric Hospitalization (s):
[select value="none|"][textarea rows="1"]

Previous Therapy:
[select value="none|"][textarea rows="1"]

Family History of Substance Use or Psychiatric Illness: 
[textarea rows="4"]

History of Suicide Attempt (s): 
[select value="none|"][textarea rows="1"]

Family History of Suicide Attempt (s) or Completed Suicide: 
[select value="none|"][textarea rows="1"]

History of Abuse:
[select value="none|"][textarea rows="1"]

History of Substance Use: 
[select value="none|"][textarea rows="1"][/conditional]


PHYSICAL EXAMINATION 

Appearance: [select value="stated age|older than stated age|younger than stated age"], [select value="neat|disheveled"][textarea memo="other" default="" rows="1"].
Gait and Station / Muscle Strength and Tone: [select name="c" value="Steady gait while walking, normal strength bilaterally|"][conditional field="c" condition="(c).is('')"]
[checkbox value="steady gait while walking|unsteady gait while walking|clumsy|unable to ambulate|in bed|in wheelchair|assisted by cane|assisted by walker|rigid|spastic|normal strength bilaterally|weakness noted in "][/conditional][textarea memo="other" default="" rows="1"].
Mood and Affect:
 Mood- [checkbox value="euthymic|depressed|anxious|angry|irritable|happy|fluctuating"][textarea memo="other" default="" rows="1"].
 Affect- [checkbox value="sad|tearful|anxious|flattened|restricted|irritable|happy|full range"][textarea memo="other" default="" rows="1"].
Speech: [select value="Normal rate and rhythm, not pressured|pressured|paucity"][textarea memo="other" default="" rows="1"].
Thought process: [select value="logical, linear, age appropriate|circumstantial|"][textarea memo="other" default="" rows="1"].
Associations: [select value="intact|loose|tangential|"][textarea memo="other" default="" rows="1"].
Thought Content: [select value="no evidence of delusions, |"][select value="no evidence of response to internal stimuli, |"][select value="no suicidal ideation or intentions, |"][select value="no homicidal ideation or intentions|"][textarea memo="other" default="" rows="1"].
Orientation: [select value="Oriented to person, place, and time|unable to assess due to cognitive impairment|"][textarea memo="other" default="" rows="1"].
Attention and Concentration: [select value="Adequate attention and concentration based on answers to interview questions|unable to assess due to cognitive impairment|impaired attention and concentration as evidenced by |"][textarea memo="other" default="" rows="1"]
Memory: [select value="Recent and remote memories both intact based on patient's answers to interview questions|unable to assess due to cognitive impairment|"][textarea memo="other" default="" rows="1"]
Language: [select value="No evidence of aphasia |unable to assess due to cognitive impairment|"][checkbox value="able to name objects|able to repeat phrases"] [textarea memo="other" default="" rows="1"]
Judgment and Insight:
 Judgment- [select value="fair|good|poor|impulsive"][textarea memo="other" default="" rows="1"].
 Insight- [select value="fair|good|poor"][textarea memo="other" default="" rows="1"]
Fund of Knowledge: Based on the answers to interview questions, patient's intelligence is judged to be [select value="average|above average|below average|unable to assess due to cognitive impairment"][textarea memo="other" default="" rows="1"]

[conditional field="b" condition="(b).is(' with psychotherapy')"]
[comment memo="Psychiatric Add On
Psychotherapy/Interactive Complexity/Prior case management
"][checkbox value="Time spent in psychotherapy: "][checkbox value="16-37 min"][comment memo="30 min 90833"][checkbox value="38-52 min"][comment memo="45 min 90836"][checkbox value="53-67 min"][comment memo="60 min 90838"]
[checkbox value="Focus of psychotherapy: "][checkbox value="interpersonal conflict|emotional experience related to diagnosis|identification of coping mechanisms|grief counseling"][textarea memo="other" default="" rows="1"]
[checkbox value="Modality: "][checkbox value="insight oriented|supportive|behavioral modification"][textarea memo="other" default="" rows="1"][/conditional]

REVIEW/MANAGEMENT
[conditional field="A" condition="(A).is('Followup')"]*Problem Status*[comment memo="
Problem status: Established-stable/improved=1pt each 
Established-worsening=2pt each 
New problem, no additional workup planned=3pt (only one) 
New problem, additional workup planned=4pt"]
The patient's progress in achieving treatment goals can best be characterized as: [checkbox value="minimal|patient is resistant|patient is making some progress|patient is working on goals, but remains symptomatic"][textarea memo="other" default="" rows="1"]

[/conditional]*Data Reviewed*
[conditional field="A" condition="(A).is('Followup')"][comment memo="1pt each, 2pt for summary"][/conditional][checkbox value="I reviewed the following notes:"][textarea default="" rows="1"][conditional field="A" condition="(A).is('Followup')"][comment memo="
1pt each, 2pts for summary"][/conditional][checkbox value=" I reviewed the following labs, imaging, consults: "][textarea default="" rows="1"][conditional field="A" condition="(A).is('Followup')"][comment memo="
1pt each, 2pts for summary"][/conditional][checkbox value=" I obtained collateral information from "][textarea default="" rows="1"][conditional field="A" condition="(A).is('Followup')"][comment memo="
2pts each"][/conditional][checkbox value=" I consulted with "][textarea memo="individual and reason for consultation" default="" rows="1"][checkbox value="I reviewed PMP|and found no abnormal results.|and found abnormal results "][textarea default="" rows="1"]

*Management*[conditional field="A" condition="(A).is('Followup')"][comment memo="
Risk/Morbidity/Mortality
Low (99213)= One stable chronic illness/Two or more slef-limited or minor problems
Moderate (99214)= Prescription meds; chronic illness with mild exacerbation or side effects of treatment; 2 or more stable chronic illnesses
High (99215)= Psychiatric illness with potential threat to self or others, drug therapy requiring intensive monitoring for toxicity; one or more chronic illnesses with severe exacerbation, progression, or side effects of treatment"][/conditional]
The following interventions were ordered/recommended this appointment:
[textarea rows="5"] [checkbox value="I discussed risks vs. benefits, as well as side effects with the patient, reviewed alternative treatments, including no treatment, and answered any questions. "][checkbox value="Medications have been discussed with parents or legal guardians. "][checkbox value="The patient and/or parent or legal guardian received medication information in the form of a medication information handout. "]

Allergies:
[textarea rows="5"]

Medication List:
[textarea rows="5"]

Diagnosis:[conditional field="A" condition="(A).is('Followup')"][comment memo="Indicate whether diagnosis changed, reason for change, date and time of change
"][/conditional][checkbox value="
Major depressive disorder|recurrent|single episode|mild|moderate|severe|
Generalized anxiety disorder|
PTSD|acute|chronic|
Adjustment Disorder|with depressed mood|with anxiety|with depressed mood and anxiety"]
[textarea rows="5"]

Significant Medical Issues:
[textarea rows="5"]

ASSESSMENT
[checkbox name="prognosis" value="" memo="Prognosis statement"][conditional field="prognosis" condition="(prognosis).is('')"]Patient is currently displaying [select value="symptoms of|well managed|moderately managed|poorly managed"] [checkbox value="depression|anxiety|sleep disturbance|psychosis|substance abuse|cognitive impairment|impulsivity|mood lability|alcohol dependence|opiate dependence|autism spectrum disorder"][textarea memo="other" default="" rows="1"] [select value="likely caused by|likely exacerbated by|likely the result of"] [checkbox value="their cancer diagnosis|their cancer treatment|their unmanaged depressive disorder|their unmanaged anxiety disorder|their unmanaged bipolar disorder|interpersonal/family conflict|current psychopharmaceutical intervention|current psychotherapy|current psychosocial support systems"][textarea memo="other" default="" rows="1"]. Patient would benefit from [checkbox value="initiation of psychopharmaceutical intervention|continued psychopharmaceutical intervention|adjustments to current psychopharmaceutical intervention|initiation of psychotherapy|continuation of current psychotherapy|engaging in grief therapy|engaging in CBT|engaging in family therapy|enhanced psychosocial supports|increasing personal time and self-care"]. [/conditional][conditional field="prognosis" condition="(prognosis).is('')"]Prognosis is [select value="good|fair|poor"] considering the patient [select value="remains adherent to|actively engages in|is not currently responding to|is not currently willing to engage in recommended|has chronically had poor response to"] medication/therapy to address [textarea memo="target of treatment" rows="1"][checkbox value=" and whether they are able to engage constructively with social supports"]. [checkbox name="barrier" value="Barriers to success include: "][/conditional][conditional field="barrier" condition="(barrier).is('Barriers to success include: ')"][checkbox value="current apprehension to engage in psychopharmaceutical intervention|current apprehension to engage in structured psychotherapy|current emotional distress of recent cancer diagnosis|limited social supports|dysfunctional interpersonal relationships"][textarea memo="barriers" rows="1"].[/conditional] [conditional field="prognosis" condition="(prognosis).is('')"][checkbox name="strength" value="Patient strength for success include: "][/conditional][conditional field="strength" condition="(strength).is('Patient strength for success include: ')"][checkbox value="expression of willingness to engage in treatment recommendations|positive social supports|are well connected with outpatient supports|history of actively engaging in mental-health treatment"][textarea memo="strengths" rows="1"].[/conditional] [textarea rows="5"]

GOALS

[checkbox name="Depression" value="-Patient will report score on PHQ-9 of "][conditional field="Depression" condition="(Depression).is('-Patient will report score on PHQ-9 of ')"][select value="8|5|6|7|8|9|10|11|12|13|14|15"] or less within [select value="3 months|1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"][checkbox name="Anxiety" value="
-Patient will report score on GAD-7 of "] [conditional field="Anxiety" condition="(Anxiety).is('
-Patient will report score on GAD-7 of ')"][select value="8|5|6|7|8|9|10|11|12|13|14|15"] or less within [select value="3 months|1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"][checkbox name="Nicotine" value="
-Patient will reduce nicotine intake by 50% within "][conditional field="Nicotine" condition="(Nicotine).is('
-Patient will reduce nicotine intake by 50% within ')"][select value="1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"][checkbox name="Sleep" value="
-Patient will experience 6+ hours of uninterrupted sleep per night within "][conditional field="Sleep" condition="(Sleep).is('
-Patient will experience 6+ hours of uninterrupted sleep per night within ')"][select value="3 months|1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"][checkbox name="Cognition" value="
-Patient will report impact of cognitive impairment as mild/resolved within "][conditional field="Cognition" condition="(Cognition).is('
-Patient will report impact of cognitive impairment as mild/resolved within ')"][select default="3" value="3 months|1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"]


PLAN:
[textarea rows="5"]

I, LTC Gregory Mabry, PsyD, LCSW, PMHNP-BC, personally examined the client obtained a history, conducted a mental status examination of the patient, and developed the plan of care.