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
________________________________________________________________________________________________________________________________________________________________________________________________

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: _____