Psychiatric Progress Note

Psychiatry
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Adult Medical History
[checklist name="Q1" value="Not Applicable|Abortion|Alcoholism|Anemia|Arthritis|Asthma|Brain Injury|Cancer, NOS|Chronic Pain|constipation|COPD|Crohn's Disease|Dental Disorders|Dizziness|Diabetes Mellitus|Drug Dependence|Emphysema|Epilepsy|Fatigue|Fibromyalgia|Hepatitis|Hypertension|HIV Infection|Irritable Bowel Syndrome|Motor Neuron Disease|Obesity|Renal Disease|Shingles|Sleep Disorder|STD|Stroke/CVA|Tuberculosis|Thyroid Disorders"]
[text]

Childhood Medical History
[checklist name="Q2" value="Not Applicable|Chicken Pox|Ear Infections|Ear Tubes|Eating Disorder|Encopresis|Enuresis|Measles|Mononucleosis|Mumps|Polio|Rheumatic Fever|Rubella|Scarlet Fever|Smallpox|Whooping Cough"]
[text]

Review of Systems
[select name="Q3" value="normal|ABNORMAL"] <-- Systemic Symptoms
[select name="Q4" value="normal|ABNORMAL"] <-- Head-related Symptoms
[select name="Q5" value="normal|ABNORMAL"] <-- Otolaryngeal Symptoms
[select name="Q6" value="normal|ABNORMAL"] <-- Cardiovascular Symptoms
[select name="Q7" value="normal|ABNORMAL"] <-- Pulmonary Symptoms
[select name="Q8" value="normal|ABNORMAL"] <-- Gastrointestinal Symptoms
[select name="Q9" value="normal|ABNORMAL"] <-- Genitourinary Symptoms
[select name="Q10" value="normal|ABNORMAL"] <-- Endocrine Symptoms
[select name="Q11" value="normal|ABNORMAL"] <-- Hematologic Symptoms
[select name="Q12" value="normal|ABNORMAL"] <-- Musculoskeletal Symptoms
[select name="Q13" value="normal|ABNORMAL"] <-- Neurological Symptoms
[select name="Q14" value="normal|ABNORMAL"] <-- Skin Symptoms
[select name="Q15" value="normal|ABNORMAL"] <-- Allergic/immunologic Symptoms
[select name="Q16" value="normal|ABNORMAL"] <-- Eye Symptoms
[text]

Trauma History
[text]

Childhood Abuse
[checklist name="Q38" value="Verbally|Physically|Sexually|Physical neglect|Cultural deprivation|Subjected to ethnic discrimination"]

Treatment History
[text]

Substance Abuse History
[text]

Family Medical History
[checklist name="Q17" value="Alcholism|Drug dependence|Anxiety Disorder NOS|Depression|Mental (Psychiatric) Disorder|Suicide Completion|Family history of ADHD|Asthma|Cancer, NOS|Coronary artery disease|Diabetes mellitus|Heart disease|Hypertension|Seizure disorder|Thyroid disorder"]
[text]

Family History
[checklist name="Q17" value="Mental disability|Recorded family history of mental illness (not retardation)|Previous psychiatric treatment|Parents divorced"]
Mother
[text] Age
[select name="Q18" value="Alive|Deceased"]
Father
[text] Age
[select name="Q19" value="Alive|Deceased"]
[text] # Siblings born
Patient is [text default="youngest, oldest, middle, etc."]
Family history of alcoholism
[select name="Q20" value="Father|Mother|Both parents"]
[checklist name="Q21" value="Death in the family"]
[text]

Current Family and Significant Relationships
[checklist name="Q22" value="Living environment secure and supportive|Lack of social support from family|Lack of social support from friends|Lack of companionship|Interpersonal problems|Family problems|Family problems - Disruption|Family problems - Estrangement|Family problems - Physically or sexually abused by family member|ETOH use affecting relationships with others|Drug use affecting personal relationships"]
[text]

Social History
[checklist name="Q23" value="Living independently with spouse|Living with parents|Living with significant other"]
Spouse
[text] Age
[select name="Q24" value="Alive|Deceased"]
[text] # Children living
[text] # Children deceased
[checklist name="Q25" value="Single|Unmarried, living together|Recent breakup with significant other|Currently married"]
[text] # Total number of marriages
[checklist name="Q26" value="Separated"]
[checklist name="Q27" value="Divorced"]
[text] # Divorced times
[checklist name="Q28" value="Recently divorced"]
[checklist name="Q29" value="Widowed"]
[checklist name="Q30" value="Annulment"]
[text]

Assessment of current relationship (if applicable)
[checklist name="Q31" value="Interpersonal relationship problems"]
Life circumstance event
[checklist name="Q32" value="Physically abused"]
[checklist name="Q33" value="Sexually abused"]
[checklist name="Q34" value="Abused as child"]
[checklist name="Q35" value="Verbally berated, harassed, intimidated"]
[checklist name="Q36" value="Neglected as child "]
[checklist name="Q37" value="Abuse/neglect"]
[text]

Mental Status Exam
Dangerousness Assessment
[checklist name="Q39" value="Previous suicide attempt|Suicidal ideation|Suicidal plan|Suicidal intent|Homicidal ideation|Homicidal plan|Homicidal intent|Repetitive self injurious|Access to weapons/guns in home"]

Testing scores
[text] PHQ score [link url="https://www.soapnote.org/mental-health/patient-health-questionnaire-phq-9-calculator/" memo="calculator"]
[text] GAD 7 score [link url="https://www.soapnote.org/mental-health/generalized-anxiety-disorder-gad-7/" memo="calculator"]
[text] CAGE-AID score [link url="https://www.soapnote.org/mental-health/cage-aid/" memo="calculator"]
[text] ZUNG score [link url="https://www.soapnote.org/mental-health/zung-depression-scale/" memo="calculator"]
[text] AD8 Dementia Screening [link url="https://www.alz.org/documents_custom/ad8.pdf" memo="paper form"]
[text] Connors Score
[text] Vanderbilt Parent Score

Physical Exam
[checklist name="Q40" value="Patient Not Examined|Head|Neck|Eyes|ENT|Lungs|Cardiovascular System|Abdomen|Musculoskeletal System|Neurological System"]

Mental Status Exam (MSE) Testing
[checklist name="Q41" value="Oriented to Time, Place, Person"]
Orientation [text]
[checklist name="Q42" value="Registration"]
[checklist name="Q43" value="Calculations"]
# Serial Sevens [text]
[checklist name="Q44" value="Recall"]
[checklist name="Q45" value="Language"]
[checklist name="Q46" value="Copying a Design"]
[text]

Appearance
[checklist name="Q47" value="Normal Appearance|Abnormal Appearance - Meticulous|Abnormal Appearance - Excessive Cosmetics|Abnormal Appearance - Unkempt|Body Odor|Uncomfortable|Appears distressed"]
[text]

Speech
[checklist name="Q48" value="Normal Speech|Abnormal Rate - Slow|Abnormal Rate - Rapid|Abnormal Rate - Pressured|Abnormal Rhythm|Abnormal Tone"]
[text]

Gait and Motor Coordination
[checklist name="Q49" value="Gait and Stance|Involuntary Movements|Posture"]
[text]

Mental Functioning
[checklist name="Q50" value="Developmental|Impaired Calculation Ability|Abnormal Immediate Recall|Impaired Memory Remote|Low Fund of Knowledge|Cognitive|Unable to spell WORLD backwards"]
[text]

Behavior
[checklist name="Q51" value="Demonstrated Behavior|Decreased Eye-To-Eye Contact|Psychomotor Retardation|Attention - easily distracted"]
[text]

Higher Order Abilities
[checklist name="Q52" value="Impaired Judgement|Impaired Insight|Abnormal Estimated Intelligence"]
[text]

Predomninat Mood
[checklist name="Q53" value="Normal|Angry|Anxious|Calm|Concerned|Depressed|Despairing|Dysphoric|Elevated|Empty|Euphoric|Expansive|Fearful|Frustrated|Futile|Guilty|Happy|Inappropriate|In Pain|Irritable|Joyous|Lability|Pleased|Unhappy|Self-contempt"]
[text]

Thought Form/Content
[checklist name="Q54" value="Thought Content|Thought Processes|Executive Functions|Delusions|Auditory Hallucinations|Visual Hallucinations"]
[text]

Cognitive and Memory
[checklist name="Q55" value="Normal Cognitive Functions|Decreased|Perceptual Disturbances|Normal Memory|Abnormal Recent Memory|Abnormal Short Term Memory|Visual Impairment|Verbal Impairment|Procedural Impairment"]
[text]


Affect
[checklist name="Q56" value="Affect Congruent with Mood|Inappropriate|Labile|Flat|Tearful|Pained Facies|Worried|Irritable|Agitated|Affect Blunted|Affect Restricted"]
[text]

Attitude
[checklist name="Q57" value="Distractible|Indifferent|Guarded|Defensive|Evasive|Bitter|Uninhibited|Ingratiating|Seductive|Inattentive|Disinterested|Uncooperative|Hostile|Full ranging|Indifferent (la belle indifference)|Blunted|Restricted|Angered"]
[text]

Risk of Suicide
[checklist name="Q58" value="Suicidal ideas|Suicidal plans|Suicidal intent|Active or passive thoughts of suicidal death|Prior suicidal ideas, plans, or attempts, including attempts that were interrupted or aborted|Prior intentional self-injury in which there was no suicidal intent"]
[text]

Risk of Aggressive Behaviors
[checklist name="Q59" value="Current or past aggressive or psychotic ideas|Thoughts of physical or sexual aggression or homicide|Past aggressive ideas or behaviors|Legal or disciplinary consequences of past aggressive behaviors|Exposure to violence or aggressive behavior, including combat exposure or childhood abuse"]
[text]

[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).isNot('')"]
Reference:
[link url="https://doi.org/10.1176/appi.books.9780890426760.pe02" memo="#1"] The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition
Adult Medical History



Childhood Medical History



Review of Systems
<-- Systemic Symptoms
<-- Head-related Symptoms
<-- Otolaryngeal Symptoms
<-- Cardiovascular Symptoms
<-- Pulmonary Symptoms
<-- Gastrointestinal Symptoms
<-- Genitourinary Symptoms
<-- Endocrine Symptoms
<-- Hematologic Symptoms
<-- Musculoskeletal Symptoms
<-- Neurological Symptoms
<-- Skin Symptoms
<-- Allergic/immunologic Symptoms
<-- Eye Symptoms


Trauma History


Childhood Abuse


Treatment History


Substance Abuse History


Family Medical History



Family History

Mother
Age

Father
Age

# Siblings born
Patient is
Family history of alcoholism




Current Family and Significant Relationships



Social History

Spouse
Age

# Children living
# Children deceased

# Total number of marriages


# Divorced times





Assessment of current relationship (if applicable)

Life circumstance event








Mental Status Exam
Dangerousness Assessment


Testing scores
PHQ score calculator
GAD 7 score calculator
CAGE-AID score calculator
ZUNG score calculator
AD8 Dementia Screening paper form
Connors Score
Vanderbilt Parent Score

Physical Exam


Mental Status Exam (MSE) Testing

Orientation


# Serial Sevens





Appearance



Speech



Gait and Motor Coordination



Mental Functioning



Behavior



Higher Order Abilities



Predomninat Mood



Thought Form/Content



Cognitive and Memory




Affect



Attitude



Risk of Suicide



Risk of Aggressive Behaviors



display/hide references
Reference:
#1 The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition
Result - Copy and paste this output:

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