PMHNP Long Note

Psychiatry & Psychology
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[date name="variable_1" default="03/26/2022"]

PMHNP Note
Subjective
Chief Complaint A statement in “quotes” describing what the patient presents for today: Please document if the condition has worsened, improved, resolved over the past weeks, months or years.
[textarea name="variable_1" default="sample text"]

History of Present Illness Provide a focused description of symptoms.
[textarea name="variable_1" default="sample text"]

Differential diagnosis, including medical (remember to use DSM5 Diagnostics and ICD codes):
[textarea name="variable_1" default="sample text"]

Symptoms supporting diiferential diagnosis:
[textarea name="variable_1" default="sample text"]

Factors that make symptoms worse:
[textarea name="variable_1" default="sample text"]

Factors that make symptoms better:
[textarea name="variable_1" default="sample text"]

Significant events since last visit:
[textarea name="variable_1" default="sample text"]

Symptom(s): (anxiety/depression) on a scale of 1 to 10 with 10 being severely (anxious/depressed):
[text name="variable_1" default="sample text"]
Appetite:(increased/decreased, number of meals daily, snacking)
[textarea name="variable_1" default="sample text"]

Sleep: (number of hours of sleep, difficulty falling asleep/staying asleep, dreams/nightmares)
[textarea name="variable_1" default="sample text"]

Clinical significance of distress/impairment in Social Setting:
[textarea name="variable_1" default="sample text"]

Clinical significance of distress/impairment in Occupational setting:
[textarea name="variable_1" default="sample text"]

Clinical significance of distress/impairment in Educational areas of functioning:
[textarea name="variable_1" default="sample text"]

If symptoms are attributable to a medical condition:

If symptoms are attributable to substance use:
Past Psychiatric History
[textarea name="variable_1" default="sample text"]

Current review of prior Inpatient psychiatric hospitalizations: (include name of facility, date of admission, length of stay, and reason for admission)
[textarea name="variable_1" default="sample text"]
Suicidality/History of self-harm: (include thoughts, active plan, attempts [present and past]
Outpatient treatments: (include name of facility, date of admission, length of stay, and reason for admission
[textarea name="variable_1" default="sample text"]
Comprehensive list of Past psychiatric medications:
[textarea name="variable_1" default="sample text"]
Highest dosages and Reasons for discontinuation:
Past/present use of Tobacco: (include type, when used, how long used, age began using, what route, tolerance, and withdrawal, last time used, and longest period of abstinence.)
[textarea name="variable_1" default="sample text"]
Past/Present use of Caffeine: (include type, when used, how long used, age began using, what route, tolerance, and withdrawal, last time used, and longest period of abstinence.)
[textarea name="variable_1" default="sample text"]
Past/present use of chemicals: (include type, when used, how long used, age began using, what route, tolerance, and withdrawal, last time used, and longest period of abstinence.)
[textarea name="variable_1" default="sample text"]
Past OTC use (ASA, NSAIDs, etc.):
[textarea name="variable_1" default="sample text"]
Past Medical History
[textarea name="variable_1" default="sample text"]
Medical diagnoses (especially endocrine, CV, seizures), Surgeries, Hx of head injury/trauma:
[textarea name="variable_1" default="sample text"]
Allergies: (document patient’s reaction(s))
[text name="variable_1" default="sample text"]
Current medication(s): (include both brand and generic names with dosage)
Length of time patient has been taking medication(s):
[textarea name="variable_1" default="sample text"]
Medication(s) helping symptom(s):
[textarea name="variable_1" default="sample text"]
Medications(s) making symptom(s) worse:
[textarea name="variable_1" default="sample text"]
Medication side effect(s):
[textarea name="variable_1" default="sample text"]
OTC medication use (ASA, NSAIDs, etc.):
[textarea name="variable_1" default="sample text"]
[PEDS] Growth and Development: Gestation, delivery, and developmental milestones
[textarea name="variable_1" default="sample text"]
Immunizations:
[Females] Last menstrual period:
[text name="variable_1" default="sample text"]
Gravida
[text name="variable_1" default="sample text"]

Family History
Include parents, grandparents, siblings, and children
[textarea name="variable_1" default="sample text"]

Psychiatric:
[textarea name="variable_1" default="sample text"]
Endocrine:
[textarea name="variable_1" default="sample text"]
Cardiovascular:
[textarea name="variable_1" default="sample text"]
Seizure:
[textarea name="variable_1" default="sample text"]
Brief Personal Social History
Born/raised:
[textarea name="variable_1" default="sample text"]
Relationships with parents/significant others:
[PEDS] also include peers and dating relationships
Schooling: Include highest grade level completed [PEDS also include if part of Individualized Education Program (IEP) or 504]
[textarea name="variable_1" default="sample text"]
Presence of a learning disorder:
Occupation name and duties
[textarea name="variable_1" default="sample text"]
Trauma:
Sexual, emotional, and physical
[textarea name="variable_1" default="sample text"]
Legal issues:
[textarea name="variable_1" default="sample text"]
Exercise:
[textarea name="variable_1" default="sample text"]
Religion and Spirituality:
[textarea name="variable_1" default="sample text"]
Objective
Vital Signs
[textarea name="variable_1" default="sample text"]
Height:
[text name="variable_1" default="sample text"]
Weight:
[text name="variable_1" default="sample text"]
BMI:
[text name="variable_1" default="sample text"]
Blood Pressure:
[text name="variable_1" default="sample text"]
Heart rate/rhythm:
[text name="variable_1" default="sample text"]
Mental Staus Exam
Constitution
Appearance:
[textarea name="variable_1" default="sample text"]
Age/gender:
[text name="variable_1" default="sample text"]

Apparent Age:
[text name="variable_1" default="sample text"]
Race/Ethnicity:
[text name="variable_1" default="sample text"]
Body build:
[text name="variable_1" default="sample text"]
Posture:
[text name="variable_1" default="sample text"]
Nutrition:
[text name="variable_1" default="sample text"]
Clothing:
[text name="variable_1" default="sample text"]
Hygiene:
[textarea name="variable_1" default="sample text"]
Hairstyle:
[text name="variable_1" default="sample text"]
Body adornments:
[text name="variable_1" default="sample text"]
Alertness & Orientation
Awareness of environment:
[textarea name="variable_1" default="sample text"]
Attention span:
[textarea name="variable_1" default="sample text"]
Level of consciousness:
Orientation to person, place, time and situation:
General Behavior
[textarea name="variable_1" default="sample text"]
Activity level:
[textarea name="variable_1" default="sample text"]
Mannerisms/Sterotypes:
[textarea name="variable_1" default="sample text"]
Facial expressions:
[textarea name="variable_1" default="sample text"]
Eye contact:
[textarea name="variable_1" default="sample text"]
Motor/Vocal tics:
[text name="variable_1" default="sample text"]
Attitude Towards Examiner.The PMHNP describes patient’s attitude towards the PMHNP examiner and provides an example.
Speech. Describe Rate and Rhythm of speech:
Mood. Document what the patient states her/his mood is during the interview Place what the patient says in “quotes”:
Affect The PMHNP’s visual assessment of the patient’s affect with statement of congruency (type, lability, appropriateness, and intensity)
Type:
[textarea name="variable_1" default="sample text"]
Lability:
[textarea name="variable_1" default="sample text"]
Appropriateness:
[textarea name="variable_1" default="sample text"]
Intensity:
[textarea name="variable_1" default="sample text"]
Thought Content
[textarea name="variable_1" default="sample text"]
Presence of suicidal/homicidal idealization:
[textarea name="variable_1" default="sample text"]
Psychotic symptoms:
[textarea name="variable_1" default="sample text"]
Hallucinations Type:
[textarea name="variable_1" default="sample text"]
Command Hallucinations:
[textarea name="variable_1" default="sample text"]
Occurrence of hallucinations during day/night/both or triggers:
[textarea name="variable_1" default="sample text"]
Delusions:
[textarea name="variable_1" default="sample text"]
Obsessions:
[textarea name="variable_1" default="sample text"]
Compulsions:
[textarea name="variable_1" default="sample text"]
Thought Process
Form of thinking:
[textarea name="variable_1" default="sample text"]
Productivity of ideas:
[textarea name="variable_1" default="sample text"]
Continuity of thought:
[textarea name="variable_1" default="sample text"]
Language impairments:
[textarea name="variable_1" default="sample text"]
Word associations:
Attention and Concentration. Serial sevens, name 5 presidents, 3 words immediate retention and recall after 5 minutes.
[textarea name="variable_1" default="sample text"]
Remote and recent memory:
[textarea name="variable_1" default="sample text"]
Immediate retention and recall:
[textarea name="variable_1" default="sample text"]
Serial events:
[textarea name="variable_1" default="sample text"]
Fund of Knowledge
Piaget stage of cognitive development according to age:
Piaget stage of cognitive development according to current state of mind:
Estimate of patient’s intellectual capability:
Abstract Thinking
Proverbs and patient’s meaning of proverbs along with appropriateness:
Similarities and differences of an apple and an orange?
Spell WORLD forwards then backwards:
Patient’s interpretation of "the grass is always greener on the other side":
Patient’s interpretation of "don’t cry over spilled milk":
Insight
Degree of personal awareness and understanding of illness. Provide examples:
Judgment. Provde examples.
Social judgment (consequences of behaviors), and test judgment:
Patient’s interpretation of "what would you do with an addressed stamped envelope:
[textarea name="variable_1" default="sample text"]
Patient’s interpretation of "what would you do with a wallet that you found on the sidewalk?"
[PEDS] Patient’s interpretation of “would you be happy if everything went the way you wanted it to go?”
Screening tools used and results
[textarea name="variable_1" default="sample text"]
Assessment
Diagnosis
Diagnosis: Provide your primary diagnosis. Use the DSM-5 and ICD diagnostic code for the diagnosis including the severity/course specifier specific to the DSM-5 diagnosis (i.e.: mild, moderate, severe, psychotic features, in partial remission, in full remission etc.) Data contained in the Subjective and Objective sections of your PMHNP note should support your diagnosis. Example: Social Anxiety Disorder (Social Phobia) 300.23 (F40.10)

Main Diagnosis:
[text name="variable_1" default="sample text"]
Plan
[textarea name="variable_1" default="sample text"]

Psychopharmacology
Trade name of medication with dosage and how to take:
[textarea name="variable_1" default="sample text"]
Amount of medication and refills:
[text name="variable_1" default="sample text"]
Generic name of medication:
[textarea name="variable_1" default="sample text"]
Was medication continued, increased, or decreased:
Non-Pharmacological. Document nursing interventions such as sleep hygiene, diet, exercise, yoga, etc.:
[textarea name="variable_1" default="sample text"]
Psychotherapy. Document a psychotherapy that has shown evidence-based research for this patient’s diagnosis. Describe how you would educate the patient as to how this psychotherapy works. Use a different psychotherapy for each PMHNP note.
Diagnostic Studies. Document diagnostic studies that were ordered and rational for ordering. If no studies were ordered, document what diagnostic studies could/should have been ordered and your rationale for ordering.
[textarea name="variable_1" default="sample text"]

Psychoeducation
Document how the patient (and guardian) was/were informed/educated on the purpose of the medication(s).
[textarea name="variable_1" default="sample text"]
Document how the patient (and guardian) was/were informed/educated on the potential risks, side effects (NMS, EPS, TD, elevated BS/lipids, rash, priapism hypotension, pregnancy, etc.
[textarea name="variable_1" default="sample text"]
Document how the patient (and guardian) was/were informed/educated on the benefits of the medication(s).
[textarea name="variable_1" default="sample text"]
Document how the patient (and guardian) was/were informed/educated about when to call/walk-in/seek emergency care.
[textarea name="variable_1" default="sample text"]
Informed Consent/Assent
Document how the patient (and guardian) was/were provided informed consent and/or assent [PEDS].
Document how the patient (and guardian) was/were informed/educated on her/his/their right, to the extent permitted by law, to refuse specific medications and/or treatments.
[textarea name="variable_1" default="sample text"]

Follow-up. Document the amount of time until next visit (2 weeks, 1 month, etc.)
[textarea name="variable_1" default="sample text"]
Referrals/Consults. Document referral/consult to where/type of provider and rationale.
[textarea name="variable_1" default="sample text"]

Comments
[textarea name="variable_1" default="sample text"]


PMHNP Note
Subjective
Chief Complaint A statement in “quotes” describing what the patient presents for today: Please document if the condition has worsened, improved, resolved over the past weeks, months or years.


History of Present Illness Provide a focused description of symptoms.


Differential diagnosis, including medical (remember to use DSM5 Diagnostics and ICD codes):


Symptoms supporting diiferential diagnosis:


Factors that make symptoms worse:


Factors that make symptoms better:


Significant events since last visit:


Symptom(s): (anxiety/depression) on a scale of 1 to 10 with 10 being severely (anxious/depressed):

Appetite:(increased/decreased, number of meals daily, snacking)


Sleep: (number of hours of sleep, difficulty falling asleep/staying asleep, dreams/nightmares)


Clinical significance of distress/impairment in Social Setting:


Clinical significance of distress/impairment in Occupational setting:


Clinical significance of distress/impairment in Educational areas of functioning:


If symptoms are attributable to a medical condition:

If symptoms are attributable to substance use:
Past Psychiatric History


Current review of prior Inpatient psychiatric hospitalizations: (include name of facility, date of admission, length of stay, and reason for admission)

Suicidality/History of self-harm: (include thoughts, active plan, attempts [present and past]
Outpatient treatments: (include name of facility, date of admission, length of stay, and reason for admission

Comprehensive list of Past psychiatric medications:

Highest dosages and Reasons for discontinuation:
Past/present use of Tobacco: (include type, when used, how long used, age began using, what route, tolerance, and withdrawal, last time used, and longest period of abstinence.)

Past/Present use of Caffeine: (include type, when used, how long used, age began using, what route, tolerance, and withdrawal, last time used, and longest period of abstinence.)

Past/present use of chemicals: (include type, when used, how long used, age began using, what route, tolerance, and withdrawal, last time used, and longest period of abstinence.)

Past OTC use (ASA, NSAIDs, etc.):

Past Medical History

Medical diagnoses (especially endocrine, CV, seizures), Surgeries, Hx of head injury/trauma:

Allergies: (document patient’s reaction(s))

Current medication(s): (include both brand and generic names with dosage)
Length of time patient has been taking medication(s):

Medication(s) helping symptom(s):

Medications(s) making symptom(s) worse:

Medication side effect(s):

OTC medication use (ASA, NSAIDs, etc.):

[PEDS] Growth and Development: Gestation, delivery, and developmental milestones

Immunizations:
[Females] Last menstrual period:

Gravida


Family History
Include parents, grandparents, siblings, and children


Psychiatric:

Endocrine:

Cardiovascular:

Seizure:

Brief Personal Social History
Born/raised:

Relationships with parents/significant others:
[PEDS] also include peers and dating relationships
Schooling: Include highest grade level completed [PEDS also include if part of Individualized Education Program (IEP) or 504]

Presence of a learning disorder:
Occupation name and duties

Trauma:
Sexual, emotional, and physical

Legal issues:

Exercise:

Religion and Spirituality:

Objective
Vital Signs

Height:

Weight:

BMI:

Blood Pressure:

Heart rate/rhythm:

Mental Staus Exam
Constitution
Appearance:

Age/gender:


Apparent Age:

Race/Ethnicity:

Body build:

Posture:

Nutrition:

Clothing:

Hygiene:

Hairstyle:

Body adornments:

Alertness & Orientation
Awareness of environment:

Attention span:

Level of consciousness:
Orientation to person, place, time and situation:
General Behavior

Activity level:

Mannerisms/Sterotypes:

Facial expressions:

Eye contact:

Motor/Vocal tics:

Attitude Towards Examiner.The PMHNP describes patient’s attitude towards the PMHNP examiner and provides an example.
Speech. Describe Rate and Rhythm of speech:
Mood. Document what the patient states her/his mood is during the interview Place what the patient says in “quotes”:
Affect The PMHNP’s visual assessment of the patient’s affect with statement of congruency (type, lability, appropriateness, and intensity)
Type:

Lability:

Appropriateness:

Intensity:

Thought Content

Presence of suicidal/homicidal idealization:

Psychotic symptoms:

Hallucinations Type:

Command Hallucinations:

Occurrence of hallucinations during day/night/both or triggers:

Delusions:

Obsessions:

Compulsions:

Thought Process
Form of thinking:

Productivity of ideas:

Continuity of thought:

Language impairments:

Word associations:
Attention and Concentration. Serial sevens, name 5 presidents, 3 words immediate retention and recall after 5 minutes.

Remote and recent memory:

Immediate retention and recall:

Serial events:

Fund of Knowledge
Piaget stage of cognitive development according to age:
Piaget stage of cognitive development according to current state of mind:
Estimate of patient’s intellectual capability:
Abstract Thinking
Proverbs and patient’s meaning of proverbs along with appropriateness:
Similarities and differences of an apple and an orange?
Spell WORLD forwards then backwards:
Patient’s interpretation of "the grass is always greener on the other side":
Patient’s interpretation of "don’t cry over spilled milk":
Insight
Degree of personal awareness and understanding of illness. Provide examples:
Judgment. Provde examples.
Social judgment (consequences of behaviors), and test judgment:
Patient’s interpretation of "what would you do with an addressed stamped envelope:

Patient’s interpretation of "what would you do with a wallet that you found on the sidewalk?"
[PEDS] Patient’s interpretation of “would you be happy if everything went the way you wanted it to go?”
Screening tools used and results

Assessment
Diagnosis
Diagnosis: Provide your primary diagnosis. Use the DSM-5 and ICD diagnostic code for the diagnosis including the severity/course specifier specific to the DSM-5 diagnosis (i.e.: mild, moderate, severe, psychotic features, in partial remission, in full remission etc.) Data contained in the Subjective and Objective sections of your PMHNP note should support your diagnosis. Example: Social Anxiety Disorder (Social Phobia) 300.23 (F40.10)

Main Diagnosis:

Plan


Psychopharmacology
Trade name of medication with dosage and how to take:

Amount of medication and refills:

Generic name of medication:

Was medication continued, increased, or decreased:
Non-Pharmacological. Document nursing interventions such as sleep hygiene, diet, exercise, yoga, etc.:

Psychotherapy. Document a psychotherapy that has shown evidence-based research for this patient’s diagnosis. Describe how you would educate the patient as to how this psychotherapy works. Use a different psychotherapy for each PMHNP note.
Diagnostic Studies. Document diagnostic studies that were ordered and rational for ordering. If no studies were ordered, document what diagnostic studies could/should have been ordered and your rationale for ordering.


Psychoeducation
Document how the patient (and guardian) was/were informed/educated on the purpose of the medication(s).

Document how the patient (and guardian) was/were informed/educated on the potential risks, side effects (NMS, EPS, TD, elevated BS/lipids, rash, priapism hypotension, pregnancy, etc.

Document how the patient (and guardian) was/were informed/educated on the benefits of the medication(s).

Document how the patient (and guardian) was/were informed/educated about when to call/walk-in/seek emergency care.

Informed Consent/Assent
Document how the patient (and guardian) was/were provided informed consent and/or assent [PEDS].
Document how the patient (and guardian) was/were informed/educated on her/his/their right, to the extent permitted by law, to refuse specific medications and/or treatments.


Follow-up. Document the amount of time until next visit (2 weeks, 1 month, etc.)

Referrals/Consults. Document referral/consult to where/type of provider and rationale.


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