Psychiatry
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[text name="variable_1" default="sample text"]
[text name="variable_1" default="sample text"]
Given the current spread of COVID 19 and this agency's limited access to comprehensive HIPAA-compliant technology, this session was completed
[checkbox name="variable_1" value="over the phone|over Zoom Telepsych platform"]


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*

Client is a [text name="variable_1" default=" "] year old[checklist name="variable_1" value="male|female"] with [text name="variable_1" default=" "] presents today for a follow-up evaluation with a chief complaint of
"[textarea memo="quotes" default="" rows="1"]"

Last seen [text name="variable_1" default=" "][comment memo="LAST VISIT"][checkbox value="the following changes were made to client's treatment: |no changes were made to client's treatment plan"][textarea memo="other" default="" rows="1"]. Client [checkbox value=" presents with new symptoms of| presents with worsening symptoms of|denies new or worsening symptoms|reports improved symptoms of|reports"][textarea memo="other" default="" rows="1"].


[checkbox memo="depression" name="dep" value=""][checkbox memo="anxiety" name="anx" value=""][checkbox memo="adhd" name="adhd" value=""][checkbox memo="sleep" name="sleep" value=""][checkbox memo="mood disorder" name="mood" value=""][conditional field="anxiety" condition="(anxiety).is('')"][/conditional][conditional field="dep" condition="(dep).is('')"]Depression is reported to be [select value="stable|better|somewhat better|somewhat worse|much worse| "][text]. [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea]. Depression is reported to be present [select value="occasionally|almost never|about 50% of the time|most of the time on most days|almost always|"][text]. Depression is rated at [select value="1|2|3|4|5|6|7|8|9|10"]/10 with 10 being the worst. [textarea][/conditional][conditional field="anx" condition="(anx).is('')"]

Anxiety is reported to be [select value="stable|better|somewhat better|somewhat worse|much worse| "][text]. [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|lack of response to medications|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea]. Anxiety is reported to be present [select value="occasionally|mostly around situational stressors|almost never|about 50% of the time|most of the time on most days|almost always|"][text]. Anxiety is rated at [select value="1|2|3|4|5|6|7|8|9|10"]/10 with 10 being the worst. [textarea][/conditional][conditional field="adhd" condition="(adhd).is('')"]

ADHD is reported to be [select value="stable|better|somewhat better|somewhat worse|much worse| "][text]. [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|lack of response to medications|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea]. Inattention is reported to be present [select value="occasionally|mostly around situational stressors|almost never|about 50% of the time|most of the time on most days|almost always|"][text]. [textarea][/conditional][conditional field="sleep" condition="(sleep).is('')"]

Sleep is reported to be [select value="stable|better|somewhat better|somewhat worse|much worse| "][text]. [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|lack of response to medications|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea]. Insomnia is reported to be present [select value="occasionally|mostly around situational stressors|almost never|about 50% of the time|most of the time on most days|almost always|"][text]. [textarea][/conditional][conditional field="mood" condition="(mood).is('')"]

Mood disorder is reported to be [select value="stable|better|somewhat better|somewhat worse|much worse| "][text]. [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|lack of response to medications|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea]. They report [checkbox value="depression|anxiety|irritability|mania|hypomania|impulsivity|emotional lability|"][text] to be present [select value="occasionally|mostly around situational stressors|almost never|about 50% of the time|most of the time on most days|almost always|"][text]. [textarea][/conditional]

[select value="They deny wanting medication changes at this time|They are open to considering further medication adjustments for the treatment of |They are requesting medication adjustments for treatment of |"][text]. [textarea]


Client reports they are sleeping on average [select name="sleep" value="0|1|2|3|4|5|6|7|8|9|10"] hours per night. Patient [comment memo="side effects"][checkbox value="denies medication side effects|endorses medication side effects"][textarea memo="other" default="" rows="1"].

[checkbox name="variable_1" value="No evidence of psychotic phenomenon;|Denies SI / HI / intent / plan|No acute medical concerns that would be contributing to current symptoms."]

*Review of Systems* [comment memo="Include for 99213 thru 99215"]

Sub use:
Last use of Cannabis: [text name="variable_1" default=" "];
Methamphetamines: [text name="variable_1" default=" "];
Cocaine: [text name="variable_1" default=" "];
Heroin: [text name="variable_1" default=" "];
EcStasy: [text name="variable_1" default=" "];
Tobacco: [text name="variable_1" default=" "];
ETOH: [text name="variable_1" default=" "];

*Past/Family/Social History* [comment memo="Include for 99214 + 99215"]
[textarea rows="3"]

Mental Status Exam [comment memo="
99212 requires 1
99213 requires 6
99214 requires 9
99215 requires ALL"]


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|rigid|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|labile|anxious|flattened|restricted|irritable|happy|full range"][textarea memo="other" default="" rows="1"]
Speech: [select value="Normal rate and rhythm, not pressured|pressured|paucity|soft"][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"]


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"]



ASSESSMENT
Patient is currently displaying [select value="symptoms of|well managed|moderately managed|poorly managed"] [checkbox value="depression|anxiety|sleep disturbance|psychosis|substance use disorder|cognitive impairment|impulsivity|mood lability|alcohol dependence|opioid 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 substance use disorder|their trauma history|their depressive disorder|their anxiety disorder|their bipolar disorder|interpersonal/family conflict|the stressors of a rigorous substance use program|maladaptive behaviors|poor psychosocial support systems"][textarea memo="other" default="" rows="1"]. Patient would benefit from [checkbox value="continued psychopharmaceutical intervention|adjustments to current psychopharmaceutical intervention|continuation of current psychotherapy|engaging in grief therapy|engaging in CBT|engaging in family therapy|enhanced psychosocial 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 psychotropic intervention|current apprehension to engage in structured substance use treatment|current emotional distress due to unresolved trauma|limited social supports|dysfunctional interpersonal relationships|poor insight"][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|high intelligence"][textarea memo="strengths" rows="1"]. [textarea rows="5"]



PLAN:
[textarea rows="5"]to treat [checkbox value="mood lability|depression|anxiety|cravings|insomnia|trauma symptoms|hallucinations|paranoia|compulsions"][textarea memo="other" default="" rows="1"]

[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. "]

Labs ordered: [checkbox value="no|yes, CBC, CMP, thyroid panel, Vit. B, Vit. D, lipid panel"][textarea memo="other" default="" rows="1"]

Follow up with PCP for acute medical concerns

Follow-up in[text name="variable_1"
default=" "]
[text name="variable_1" default="sample text"]


Given the current spread of COVID 19 and this agency's limited access to comprehensive HIPAA-compliant technology, this session was completed



HISTORY OF PRESENTING PROBLEM
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*

Client is a year old with presents today for a follow-up evaluation with a chief complaint of
"quotes"

Last seen LAST VISIT other. Client other.


depression anxiety adhd sleep mood disorder

.


Client reports they are sleeping on average hours per night. Patient side effects other.



*Review of Systems* Include for 99213 thru 99215

Sub use:
Last use of Cannabis: ;
Methamphetamines: ;
Cocaine: ;
Heroin: ;
EcStasy: ;
Tobacco: ;
ETOH: ;

*Past/Family/Social History* Include for 99214 + 99215


Mental Status Exam
99212 requires 1
99213 requires 6
99214 requires 9
99215 requires ALL



Appearance: , other
Gait and Station / Muscle Strength and Tone: other
Mood and Affect:
Mood- other
Affect- other
Speech: other
Thought process: other
Associations: other
Thought Content: other
Orientation: other
Attention and Concentration: other
Memory: other
Language: other
Judgment and Insight:
Judgment- other
Insight- other
Fund of Knowledge: Based on the answers to interview questions, patient's intelligence is judged to be other


REVIEW/MANAGEMENT
*Problem Status*
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: other

*Data Reviewed*
1pt each, 2pt for summary
1pt each, 2pts for summary

1pt each, 2pts for summary

2pts each
individual and reason for consultation



ASSESSMENT
Patient is currently displaying other which is other. Patient would benefit from other. Prognosis is considering the patient medication/therapy to addresstarget of treatment . barriers. strengths.



PLAN:
to treat other



Labs ordered: other

Follow up with PCP for acute medical concerns

Follow-up in

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