clinical prog note

CLINICAL PROGRESS NOTE: FOLLOW-UP VISIT

Date of Service: ____________________

Start Time: ______a.m. _______ p.m. Patient’s Name: __________________________________

Stop Time: ______ a.m. _______ p.m. MR Number: __________________________________


__ Patient was seen and examined in person
__ Chart reviewed
__ Labs reviewed
__ Patients case discussed with staff

CHIEF COMPLAINT
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INTERIM HISTORY
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Appetite: __ Normal/Unchanged __Increase __ Decrease SI: ___ Present ___Absent
Sleep: __ Normal/Unchanged __ Increase __ Decrease HI: ___ Present ___ Absent
Energy: __ Normal/Unchanged __ Increase __ Decrease Plan: ___ Present ___ Absent
Patient is: ___ able ___ not able to contract for safety ___N/A Aggression: ___ Yes ___ No
Medication Side Effects (SE): ___None (Psych. Meds.) ___ Other ___
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EXAMINATION

Vital signs: Temp_________ HR_________ Resp__________ BP__________
Appearance: ____________________________ Gait: _______________________________________
Level of Consciousness: _____Alert ____ Drowsy ____ Lethargic ____Non-Arousable


MENTAL STATUS

Orientation: Date/Time: ___ yes ___ no place ___ yes ___ no Person ___ yes ___ no

Manner: ___ Cooperative ___ Guarded ___ Suspicious ___ Irritable ___ Hostile ___Withdrawn ___ Other ________________________________________________________________________________________________________________________________________________________________________________________________

or Activity: ___ Normal ___ Agitation ___ Motor Retardation ___ Tremor ___ Other

Musculoskeletal: ___ Normal ___ Rigidity ___ Cogwheel ___Flaccid ___Tics/TD ___ Other

Speech: ___ Normal ___ Soft/Loud ___ Slow/Pressured ___ Dysarthric ___ Incoherent ___Other

Language: ___ Normal ___Expressive ___Fluent Aphasia ___ Other ____

Fund of Knowledge: _______Intact ________Fair ________ Poor __________Other

Mood: ___ Euthymic ___ Depressed ___ Irritable ___Angry ___ Anxious ___ Fearful
___ Apathetic ___ Euphoric ___Other

Affect: ___ Euthymic ___Depressed ___Blunted ___Flat ___Irritable ___ Angry
___Anxious ___Labile ___Expansive ___Exaggerated ___Other



Thought Process/Association: ___Normal ___Tangential ___Circumstantial ___Poverty of Thought
___Concrete ___Disorganized ___Racing Thoughts ___Flight of Ideas
___ Loose ___Other

Thought Contents: ___Normal ___Hopelessness ___Worthlessness ___Hypochondriasness ___Delusions
___Paranoia ___Ruminations ___Confused ___Obsessions/Compulsions ___Other

Perception: ___ Normal ___Hallucinations ___Auditory ___Visual ___Olfactory ___Tactle ___ Command Hallucinations ___Dissociation ___Flashbacks ___Other

Attention/Concentration: ___Intact ___Poor ___Distractible ___Redirectable ___Other

Cognition: ___Intact ___Impaired Insight: ___Intact ___Fair ___Limited

Short Term Memory: ___Intact ___Fair ___Poor Judgment: ___Intact ___Fair ___Limited

Remote Memory: ___Intact ___Fair ___Poor


PAST MEDICAL/PSYCHIATRIC HISTORY:
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FAMILY/SOCIAL HISTORY:
____Unchanged from history documented in initial psychiatric evaluation and subsequent notes
____New Information:
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ROS:

Explain positives (circle items) below.

Constitutional Neg__________ Pos__________
Eyes Neg__________ Pos__________
Ears/Nose/Mouth/Throat Neg__________ Pos__________
CV Neg___________ Pos__________
Respiratory Neg___________ Pos__________
GI Neg___________ Pos__________
GU Neg___________ Pos__________
Musculoskeletal Neg___________ Pos__________
Skin/Breast Neg___________ Pos__________
Neurological Neg___________ Pos__________
Endocrine Neg___________ Pos__________
Heme/Lymph Neg___________ Pos__________
Allergic Immunologic Neg___________ Pos__________

Additional ROS comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


MEDICATIONS:
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PSYCHOTHERAPY/ COUNSELING: ___Therapeutic Interview ___ Supportive ___ CBT ___ Ongoing ___Other ________________________________________________________________________________________________ ________________________________________________________________________________________________

ASSESSMENT: Patient is: ___ Well-controlled ___ Improving ___ Worsening ___ Other ________________________________________________________________________________________________________________________________________________________________________________________________

DIAGNOSES (Psychiatric and Medical Diagnoses that affect psychiatric management) :
1.__________________________________________________________________________
2. __________________________________________________________________________
3. __________________________________________________________________________
4. __________________________________________________________________________
5. __________________________________________________________________________
6. __________________________________________________________________________
7. __________________________________________________________________________

TREATMENT/PLAN: ___ Continue Current Medications ___Continue Follow-Up ___Continue Labs ___ Other
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PATIENT RESPONSE TO TREATMENT:
________________________________________________________________________________________________________________________________________________________________________________________________

Risks, benefits, Side Effects, Drug-to-Drug Interactions and Alternatives to treatment were discussed in my usual manner: ____ Yes ____No

Reason for not reducing medication dose(s):
____N/A ____ High risk of patient’s deterioration ___ Medication recently reduced
___Prior Medication Dose Reduction Unsuccessful ____Other
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Complexity Issues:
# of diagnoses or management options: ____Limited ____Multiple

Problems: (gait, hearing, vision, etc.) effect on treatment and management: ____Yes ____ No

Risk of complications and/or morbidity or mortality: ____None ____ Limited ____ Moderate ____ Severe

Coord. of Care (e.g. with patient and/or family, social workers, nursing staff, other doctors):
____None ____>50% of visit ____<50% of visit

Topics discussed:
___Nature of diagnosis and/or prognosis ___ Medical records reviewed
___Aspects of aging process and relationship to the current problem ___Communication with patient’s Dr
___Nature of possible treatment options/drug drug interaction ___Communication with facility staff
___Risk of non-treatment ___Communication with family/caregiver
___Psychopharmacologic treatment options/possible benefits and risks ___Referred for psychotherapy
___Nature of, reasons for and possible benefits from psychotherapy ___ Forms/reports filled out
___Family and/or situational stressors ___Other
___Behavioral and/or environmental changed that might help

Treatment recommendations/ follow-up:

Physician name: __________________________________________________________________________________

Signature: ______________________________________________________ Date: _____