Followup Master

Assessment & Plan Elements
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NOTE
[text size="10"] [checkbox value="encounter by student|Ongoing treatment by psychiatric provider|Routine followup|discharge planning|family therapy|observation only|shared approach|Student led"]

REFERRAL
no additions, deletions, or revisions

CURRENT ENCOUNTER HX & CONTENT
[textarea rows="8"]
Patient denies [checkbox value="Suicidal ideation|Homicidal ideation|Self-harm thoughts|Auditory Hallucinations|Visual Hallucinations|Tactile Hallucinations|Difficulty with sleep|Difficulty with appetite|Mood Instability|Adverse effects of medications|Pain/physical complaints"]
Patient reports positive for [checkbox value="Suicidal ideation|Homicidal ideation|Self-harm thoughts|Auditory Hallucinations|Visual Hallucinations|Tactile Hallucinations|Difficulty with sleep|Difficulty with appetite|Mood Instability|Adverse effects of medications|Pain/physical complaints"]
Affect is [checkbox value="flat|blunted|constricted|labile|bright"]
Mood is [checkbox value="anxious|dysphoric|depressed|irritable|tearful|sad|agitated|fearful|euthymic|euphoric"]
Thought process is [checkbox value="Reality based|Disorganized|Circumstantial|tangential|flight of ideas|loose association|perseveration|thought blocking|ideas of reference|grandiose|paranoid|persecutory|religious|somatic|self accusatory"]
Speech is [checkbox value="regular rate and rhythm|rapid|slow|rambling|slurred|monotone|pressured|laconic"]
Gait is [checkbox value="regular|irregular|shuffling|unsteady"]
No observed [checkbox value="psycho-motor agitation|internal preoccupation|response to internal stimuli"]

PAST PSYCH HX
[checkbox value="no additions, deletions, or revisions"][textarea rows="1"]

Hobbies/Acitivities/Habits/Occupation
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PAST/CURRENT MED HX
no additions, deletions, or revisions

LAB WORK:
[checkbox value="no additions, deletions, or revisions"] [checkbox value="Lithium level:"] [textarea memo="0.8-1.2 mEq/L" rows="1"] [checkbox value="Depakote Level:"] [textarea memo="50-110 mcg/mL" rows="1"] [checkbox value="Tegretol Level:"] [textarea memo="5-12 mcg/mL" rows="1"] [checkbox value="Clozapine Level:"] [textarea memo="250-350 ng/mL" rows="1"] [checkbox value="H A1c:"] [textarea memo=">5.7%. 5.7-6.4 = prediabetes" rows="1"] [checkbox value="EKG QTC:"] [textarea memo="360-440 ms" rows="1"] [checkbox value="Ammonia Level:"] [textarea memo="Adults 9.5-49 mcg/dL Child 40-80 mcg/dL" rows="1"] [checkbox value="Prolactin Level:"] [textarea memo="male 2-18ng/mL. female 2-29 ng/mL. pregnant women 10-209ng/mL" rows="1"]

RX HX:
[checkbox value="no additions, deletions, or revisions"][textarea rows="1"]

Current RX:
[checkbox value="no additions, deletions, or revisions"][textarea rows="1"]

DSM - 5 (ICD - 10 Code) Diagnositics:
The Following are based on currently available info and may be changed as additional info becomes available
[checkbox value="no additions, deletions, or revisions"] [textarea rows="8"]

Applicable Z Codes
[checkbox value="no additions, deletions, or revisions"] [textarea rows="8"]

ENCOUNTER THERAPEUTIC & MEDICAL/MEDICATION MANAGEMENT INTERVENTIONS
Instruments/screening tools, results, & meaning:[textarea rows="1"]
Particular psychotherapeutic strategies used: Person centered therapy, unconditional positive regard, active listening, reflection of feeling.[textarea rows="1"]
Particular medical/medication management strategies:[textarea rows="1"]
Particular psychoeducative strategies:[textarea rows="1"]

DISPOSITION, INSTRUCTIONS, RECOMMENDATIONS, PLAN
[textarea rows="8"]

OWN OBSERVATIONS/IMPRESSIONS
[textarea rows="8"]
NOTE


REFERRAL
no additions, deletions, or revisions

CURRENT ENCOUNTER HX & CONTENT

Patient denies
Patient reports positive for
Affect is
Mood is
Thought process is
Speech is
Gait is
No observed

PAST PSYCH HX


Hobbies/Acitivities/Habits/Occupation
no additions, deletions, or revisions

PAST/CURRENT MED HX
no additions, deletions, or revisions

LAB WORK:
0.8-1.2 mEq/L 50-110 mcg/mL 5-12 mcg/mL 250-350 ng/mL >5.7%. 5.7-6.4 = prediabetes 360-440 ms Adults 9.5-49 mcg/dL Child 40-80 mcg/dL male 2-18ng/mL. female 2-29 ng/mL. pregnant women 10-209ng/mL

RX HX:


Current RX:


DSM - 5 (ICD - 10 Code) Diagnositics:
The Following are based on currently available info and may be changed as additional info becomes available


Applicable Z Codes


ENCOUNTER THERAPEUTIC & MEDICAL/MEDICATION MANAGEMENT INTERVENTIONS
Instruments/screening tools, results, & meaning:
Particular psychotherapeutic strategies used: Person centered therapy, unconditional positive regard, active listening, reflection of feeling.
Particular medical/medication management strategies:
Particular psychoeducative strategies:

DISPOSITION, INSTRUCTIONS, RECOMMENDATIONS, PLAN


OWN OBSERVATIONS/IMPRESSIONS
Result - Copy and paste this output:

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