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Psychiatry Progress Note

posted 2020-11-25, updated 2021-02-07

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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
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

Childhood Medical History
Not Applicable Chicken Pox Ear Infections Ear Tubes Eating Disorder Encopresis Enuresis Measles Mononucleosis Mumps Polio Rheumatic Fever Rubella Scarlet Fever Smallpox Whooping Cough

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
Verbally Physically Sexually Physical neglect Cultural deprivation Subjected to ethnic discrimination

Treatment History

Substance Abuse History

Family Medical History
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

Family History
Mental disability Recorded family history of mental illness (not retardation) Previous psychiatric treatment Parents divorced
Mother
Age

Father
Age

# Siblings born
Patient is
Family history of alcoholism

Death in the family

Current Family and Significant Relationships
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

Social History
Living independently with spouse Living with parents Living with significant other
Spouse
Age

# Children living
# Children deceased
Single Unmarried, living together Recent breakup with significant other Currently married
# Total number of marriages
Separated
Divorced
# Divorced times
Recently divorced
Widowed
Annulment

Assessment of current relationship (if applicable)
Interpersonal relationship problems
Life circumstance event
Physically abused
Sexually abused
Abused as child
Verbally berated, harassed, intimidated
Neglected as child
Abuse/neglect

Mental Status Exam
Dangerousness Assessment
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
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
Patient Not Examined Head Neck Eyes ENT Lungs Cardiovascular System Abdomen Musculoskeletal System Neurological System

Mental Status Exam (MSE) Testing
Oriented to Time, Place, Person
Orientation
Registration
Calculations
# Serial Sevens
Recall
Language
Copying a Design

Appearance
Normal Appearance Abnormal Appearance - Meticulous Abnormal Appearance - Excessive Cosmetics Abnormal Appearance - Unkempt Body Odor Uncomfortable Appears distressed

Speech
Normal Speech Abnormal Rate - Slow Abnormal Rate - Rapid Abnormal Rate - Pressured Abnormal Rhythm Abnormal Tone

Gait and Motor Coordination
Gait and Stance Involuntary Movements Posture

Mental Functioning
Developmental Impaired Calculation Ability Abnormal Immediate Recall Impaired Memory Remote Low Fund of Knowledge Cognitive Unable to spell WORLD backwards

Behavior
Demonstrated Behavior Decreased Eye-To-Eye Contact Psychomotor Retardation Attention - easily distracted

Higher Order Abilities
Impaired Judgement Impaired Insight Abnormal Estimated Intelligence

Predomninat Mood
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

Thought Form/Content
Thought Content Thought Processes Executive Functions Delusions Auditory Hallucinations Visual Hallucinations

Cognitive and Memory
Normal Cognitive Functions Decreased Perceptual Disturbances Normal Memory Abnormal Recent Memory Abnormal Short Term Memory Visual Impairment Verbal Impairment Procedural Impairment

Affect
Affect Congruent with Mood Inappropriate Labile Flat Tearful Pained Facies Worried Irritable Agitated Affect Blunted Affect Restricted

Attitude
Distractible Indifferent Guarded Defensive Evasive Bitter Uninhibited Ingratiating Seductive Inattentive Disinterested Uncooperative Hostile Full ranging Indifferent (la belle indifference) Blunted Restricted Angered

Risk of Suicide
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

Risk of Aggressive Behaviors
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

display/hide references
Reference:
#1 The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition

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