Psych Follow-up note ADHD

Clinical Site: Center for ADHD

Service Date: [date name="variable_1"]

Semester: Spring 2021

Demographics 
• Initials: [text]
• Age: [text]        
• Gender: [select name="variable_2" value="Female|Male|Does not identify with a particular gender"]
• Race: [select name="variable_3" value="Caucasian|African-American|Hispanic"]              
• Insurance: [select name="variable_4" value= "Private|Medicaid"]                          
• Referral: No referral needed 
• Primary Code: [text]     
• Length of Service: [text] minutes

Chief Complaint: Medication Management (Follow-up)          

HPI: The patient, who is the primary medical decision maker, physically attended today’s session. Today they state, "[text]". Patient has a history of inattentiveness, distractibility, impulsivity, over activity, and irritability. They are prescribed, and report taking [text]. They report an improved mood and increased duration of focus with this regimen. They report improved thought processing, decreased pressured speech, and improved abilities to return to tasks. They report decreased over activity, decreased irritability, and decreased impulsivity. They deny symptoms of mania or psychosis. They deny obsessive thoughts or ritualistic behaviors. They deny suicidal thoughts or ideation. They deny symptoms of PTSD or unresolved grief. Denies nightmares or separation issues. There is no history of substance abuse. They report eating [text] meals per day and sleeping [text] hours per night. Patient reports [text] side effects. They deny any other somatic complaints. Patient is encouraged to maintain a balanced diet and regular exercise regimen. Discussed medication regimen, and patient agrees to continue taking [text]. RVBSE discussed, and patient verbalizes understanding. 

Medications: 
• [text]	      


Allergies: 
• [text]	     

PMH: 
• [text]	     


Review of Systems
General: Denies any current health issues. A review of systems and organs is noncontributory for constitutional, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, musculoskeletal, gastrointestinal, allergic/immunologic, hematologic/lymphatic, general genitourinary, sex-specific genitourinary, neurological, integumentary, and endocrine issues.

Today’s Vital Signs:
• BP: [text]     
• HR: [text]     
• RR: [text]      
• Height (inches): [text]      
• Weight (lbs.): [text]      

• Sleep: Denies any difficulty sleeping	     

• Appetite: Denies any issues with appetite      

Mental Status Exam
• Appearance: [select name="variable_5" value="Average|Petite|Stocky"] build, [select name="variable_6" value="average|short|tall"] stature, 
[select name="variable_7" value="appears stated age|appears older than stated age|appears younger than stated age"]
• Alertness: [select name="variable_8" value="Intact|Diminished"]
• Expression: [select name="variable_9" value="Relaxed|Sad|Angry|Tense|Tearful"]
• Hygiene: [select name="variable_10" value="Well-groomed|Disheveled"]
• Dress: [select name="variable_11" value="Clothing clean and tidy|Inappropriate dress for conditions|Clothing dirty/stained"]

Behavior:
• Psychomotor Activity: [select name="variable_12" value="No abnormal movements noted|Hyperactive|Hypoactive"]
• Mood: "[text]"
• Affect: [select name="variable_13" value="Euthymic|Elevated|Dysphoric|Blunted|Tearful|Inappropriate"]
• Eye Contact: [select name="variable_14" value="Good|Poor|Variable"]
• Speech: [select name="variable_15" value="Regular rate, rhythm, articulation|Slowed|Soft|Loud|Pressured"]
• Thought Process: Goal-directed/logical
• Thought Content - Hall/Del/SI/HI: Denies having any current AH/VH/SI/HI
• Sensorium/Cognition/Orientation/memory: AAO to person, place, time, situation
• Insight: [select name="variable_16" value="Full|Moderate|Limited"]
• Judgement: [select name="variable_17" value="Full|Moderate|Limited"]
• Attention/Concentration: [select name="variable_18" value="Full|Moderate|Limited"]
• Intelligence: [select name="variable_19" value="High|Average|Below average"]

Diagnosis: 
• [text]	     


Treatment/Plan of Care: 
• Continue [text]     
• RVBSE explained to patient who verbalizes understanding
• Emergency plan in place
• Greater than 50% of session was spent on counseling and/or coordination of care.
• Patient is aware of how to contact clinical providers if concerns arise, and all questions addressed/answered.
• RTC in [select name="variable_20" value="3 months|1 month"], or sooner if needed