PMHNP Long Note

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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.
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History of Present Illness Provide a focused description of symptoms.
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Differential diagnosis, including medical  (remember to use DSM5 Diagnostics and ICD codes):
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Symptoms supporting diiferential diagnosis:
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Factors that make symptoms worse:
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Factors that make symptoms better:
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Significant events since last visit:
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Symptom(s): (anxiety/depression) on a scale of 1 to 10 with 10 being severely (anxious/depressed):
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Appetite:(increased/decreased, number of meals daily, snacking)
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Sleep: (number of hours of sleep, difficulty falling asleep/staying asleep, dreams/nightmares)
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Clinical significance of distress/impairment in Social Setting:
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Clinical significance of distress/impairment in Occupational setting:
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Clinical significance of distress/impairment in Educational areas of functioning:
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If symptoms are attributable to a medical condition:

If symptoms are attributable to substance use:
Past Psychiatric History
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Current review of prior Inpatient psychiatric hospitalizations: (include name of facility, date of admission, length of stay, and reason for admission)
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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
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Comprehensive list of Past psychiatric medications:
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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.)
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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.)
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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.)
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Past OTC use (ASA, NSAIDs, etc.):
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Past Medical History
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Medical diagnoses (especially endocrine, CV, seizures), Surgeries, Hx of head injury/trauma:
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Allergies: (document patient’s reaction(s))
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Current medication(s): (include both brand and generic names with dosage)
Length of time patient has been taking medication(s):
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Medication(s) helping symptom(s):
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Medications(s) making symptom(s) worse:
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Medication side effect(s):
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OTC medication use (ASA, NSAIDs, etc.):
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[PEDS] Growth and Development: Gestation, delivery, and developmental milestones
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Immunizations:
[Females] Last menstrual period:
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Gravida 
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Family History
Include parents, grandparents, siblings, and children
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Psychiatric:
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Endocrine:
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Cardiovascular:
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Seizure:
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Brief Personal Social History
Born/raised:
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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]
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Presence of a learning disorder:
Occupation name and duties
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Trauma:
Sexual, emotional, and physical
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Legal issues:
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Exercise:
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Religion and Spirituality:
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Objective
Vital Signs
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Height:
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Weight:
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BMI:
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Blood Pressure:
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Heart rate/rhythm:
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Mental Staus Exam
Constitution
Appearance:
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Age/gender:
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Apparent Age:
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Race/Ethnicity:
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Body build:
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Posture:
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Nutrition:
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Clothing:
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Hygiene:
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Hairstyle:
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Body adornments:
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Alertness & Orientation
Awareness of environment:
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Attention span:
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Level of consciousness:
Orientation to person, place, time and situation:
General Behavior
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Activity level:
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Mannerisms/Sterotypes:
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Facial expressions:
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Eye contact:
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Motor/Vocal tics:
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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:
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Lability:
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Appropriateness:
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Intensity:
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Thought Content
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Presence of suicidal/homicidal idealization:
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Psychotic symptoms:
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Hallucinations Type:
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Command Hallucinations:
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Occurrence of hallucinations during day/night/both or triggers:
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Delusions:
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Obsessions:
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Compulsions:
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Thought Process
Form of thinking:
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Productivity of ideas:
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Continuity of thought:
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Language impairments:
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Word associations:
Attention and Concentration. Serial sevens, name 5 presidents, 3 words immediate retention and recall after 5 minutes.
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Remote and recent memory:
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Immediate retention and recall:
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Serial events:
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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:
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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
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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:
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Plan
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Psychopharmacology
Trade name of medication with dosage and how to take:
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Amount of medication and refills:
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Generic name of medication:
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Was medication continued, increased, or decreased:
Non-Pharmacological. Document nursing interventions such as sleep hygiene, diet, exercise, yoga, etc.:
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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.
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Psychoeducation
Document how the patient (and guardian) was/were informed/educated on the purpose of the medication(s).
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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.
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Document how the patient (and guardian) was/were informed/educated on the benefits of the medication(s).
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Document how the patient (and guardian) was/were informed/educated about when to call/walk-in/seek emergency care.
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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.
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Follow-up. Document the amount of time until next visit (2 weeks, 1 month, etc.)
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Referrals/Consults. Document referral/consult to where/type of provider and rationale.
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Comments
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