OP F/U note ******

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="Other" default="" rows="1"]

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Patient remains [comment memo="SYMPTOM"][checkbox value="depressed|anxious|aggressive|impulsive|inattentive|irritable|withdrawn|unable to sleep|delusional|auditory hallucinations|visual hallucinations"][textarea memo="other" default="" rows="1"].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

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"]

*Review of Systems* [comment memo="Include for 99213 thru 99215"]
The patient identifies the following symptoms: [comment memo="Pertinent System "]
Psychiatric - [checkbox value="irritability|mood instability|heightened anxiety|attention problems|troubled by hallucinations|fearfulness|nightmares|alcohol cravings|opiate cravings"][textarea memo="other" default="" rows="1"]
Neurological - [checkbox value="Headaches|weakness|disturbed sleep|denied headaches, weakness, or balance issues"][textarea memo="other" default="" rows="1"]
GI - [checkbox value="Upset stomach|nausea|constipation|heartburn|denied upset stomach / N/V / Constipation / GI bleed"][textarea memo="other" default="" rows="1"]
All other systems are reviewed and are negative.

*Past/Family/Social History* [comment memo="Include for 99214 + 99215"]
[textarea default="Past medical, family, and social history was reviewed today from initial psychiatric evaluation intake. No new data available at this time." rows="3"]

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"]

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"]


[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
*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"]

*Data Reviewed*
[comment memo="1pt each, 2pt for summary"][checkbox value="I reviewed the following notes:"][textarea default="" rows="1"][comment memo="
1pt each, 2pts for summary"][checkbox value=" I reviewed the following labs, imaging, consults: "][textarea default="" rows="1"][comment memo="
1pt each, 2pts for summary"][checkbox value=" I obtained collateral information from "][textarea default="" rows="1"][comment memo="
2pts each"][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*[comment memo="
Risk/Morbidity/Mortality
Low (99213)= One stable chronic illness/Two or more self-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"]
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"][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"]

Allergies:
[textarea default="NKDA" rows="5"]

Significant Medical Issues:
[textarea default="No acute / chronic medical issues at this time." 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 poorly managed depressive disorder|their poorly managed anxiety disorder|their poorly managed bipolar disorder|interpersonal/family conflict|current psycho-pharmaceutical intervention|current psychotherapy|current psycho-social support systems"][textarea memo="other" default="" rows="1"]. Patient would benefit from [checkbox value="continued psycho-pharmaceutical intervention|adjustments to current psycho-pharmaceutical intervention|continuation of current psychotherapy|engaging in grief therapy|engaging in CBT|engaging in family therapy|enhanced psycho-social supports|increasing personal time and self-care"][textarea memo="other" rows="1"]. Prognosis is [select value="good|fair|poor"] considering the patient [select value="remains adherent to|actively engages in|is not currently responding 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 value="Barriers to success include: "][checkbox value="current apprehension to engage in psycho-pharmaceutical 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 "][textarea rows="1"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][checkbox value="
-Patient will report score on GAD-7 of 8 or less within 3 months: Initiated "][textarea rows="1"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][checkbox value="
-Patient will reduce nicotine intake by 50% within one month: Initiated "][textarea rows="1"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][checkbox value="
-Patient will experience 6+ hours of uninterrupted sleep per night within 3 months: Initiated "][textarea rows="1"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][checkbox value="
-Patient will report impact of cognitive impairment as mild/resolved within 3 months: Initiated "][textarea rows="1"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"]

PLAN:
[textarea default="" rows="5"]

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