Mental Status Exam-Comprehensive JV

HISTORY OF PRESENTING PROBLEM[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"]

*Chief Complaint*
Date and Time of Service:[date default="today"] [text size="8"]
Patient is see in this intake 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" default="" rows="1"]

*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presents as [comment memo="SYMPTOM"][checkbox value="depressed|anxious|aggressive|impulsive|inattentive|irritable|withdrawn|unable to sleep|delusional|auditory hallucinations|visual hallucinations"] [textarea memo="other" default="" rows="1"]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"]
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"]

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"]

Current Substance Use:  
[select value="Denied|Reports positive for "][checkbox value="alcohol|tobacco|cannabis|opiate use|methamphetamine use"] [textarea rows="1"]

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"]
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"]

*Review of Systems* [comment memo="Include for 99213 thru 99215"]
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* [comment memo="Include for 99214 + 99215"]
[textarea rows="3"]
Social Supports:
[checkbox value="none|significant other|extended family|children|friends|church members"]

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|"]

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

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

Legal Concerns:
[select value="denied|"][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"]

PHYSICAL EXAMINATION [comment memo="
99212 requires 1
99213 requires 6
99214 requires 9
99215 requires ALL"]

Vital Signs:
    Temp- [text size="8"]
    Pulse- [text size="8"]
    BP- [text size="8"]
    Resp- [text size="8"]
    Weight- [text size="8"]
    Height- [text size="8"]
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 value="Steady gait while walking, normal strength bilaterally|"][checkbox value="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 "][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 |"][select value="|, able to name objects|[select value="|, able to repeat phrases"][select value="|unable to assess due to cognitive impairment"][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"]

[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"]

REVIEW/MANAGEMENT
[checkbox value="I reviewed the following notes: "][textarea default="" rows="1"][checkbox value=" I reviewed the following labs, imaging, consults: "][textarea default="" rows="1"][checkbox value=" I obtained collateral information from "][textarea default="" rows="1"][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"]

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. "]

Medication List:
[textarea rows="5"]

Diagnosis:[comment memo="Indicate whether diagnosis changed, reason for change, date and time of change"]
[textarea rows="5"]

Allergies:
[textarea rows="5"]

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

ASSESSMENT
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"] which is [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"]. Prognosis is [select value="good|fair|poor"] considering the patient [select value="remains adherent to|actively engages in"] medication and therapy to address [textarea memo="target of treatment" rows="1"][checkbox value=" and whether they are able to engage constructively with social supports"]. [checkbox value="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"]. [checkbox value="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"].  [textarea rows="5"]


GOALS
[checkbox value="-Patient will report score on PHQ-9 of 8 or less within 3 months: Initiated this appointment "][textarea rows="1"][checkbox value="
-Patient will report score on GAD-7 of 8 or less within 3 months: Initiated this appointment "][textarea rows="1"][checkbox value="
-Patient will reduce nicotine intake by 50% within one month: Initiated this appointment "][textarea rows="1"][checkbox value="
-Patient will experience 6+ hours of uninterrupted sleep per night within 3 months: Initiated this appointment "][textarea rows="1"][checkbox value="
-Patient will report impact of cognitive impairment as mild/resolved within 3 months: Initiated this appointment "][textarea rows="1"]

PLAN:
[textarea rows="5"]

I, Chase Cardurns PMHNP-BC, personally examined the client obtained a history, conducted a mental status examination of the patient, and developed the plan of care.