NP Beginning up until Psych Hx

Outpatient Psychiatry Note

Telemedicine was performed per regulatory requirements as the practice of health care delivery, diagnosis, consultation and treatment and the transfer of medical data between the originating and distant sites through real time interactive audio, video or data communications that occur in the physical presence of the member.The patient expressed understanding of the information provided regarding telehealth/telemedicine, all of their questions have been answered to the patient's satisfaction and verbal informed consent for the use of telehealth/telemedicine was provided to this provider. Patient has a right to rescind the use of telecommunication recording at any time. 

CC: New Patient Evaluation				

HPI: [text name="variable_1" default="Name"]is a [text name="variable_2" default="Age"] year-old [select name="variable_3" value="female|male|"] presenting today for Psychiatric evaluation and medication management.

[textarea name="4" default="sample text"][comment memo="HPI"]

Patient reports these symptoms have caused marked impairment in their daily life. Patient and provider discuss medication treatment options to manage mental health symptoms as patient would likely benefit from treatment to reduce the severity and frequency of these mental health concerns. Patient denies suicidal ideation, homicidal ideation, auditory or visual hallucination. There is no delusional thought content endorsed or observed, and patient is not noted to exhibit symptoms of psychosis or mania. Patient is calm, cooperative and logical and linear in their thought process with no acute DTS, DTO behavior or statements. Patient is goal and future oriented to participate in mental health treatment. Patient's insight and judgment are intact.					

THERAPY: [text name="4.1" default="sample text"]

ALLERGIES: [text name="4" default="NKDA"] 

CURRENT MEDICATIONS: SEE RX LIST

Past psychiatric, medical, social & family history reviewed today and updated as warranted.