This post is long overdue and caution, it is LONG. Here’s a collection of documentation formats and particular words to not only be accurate but also neutral/non-judgmental, clear, and most importantly increase efficiency and getting PAID. Countless businesses and health facilities have FAILED because they don’t know how to bill or capture services. And I’ve discussed it before. This is important for ALL providers, if you’re documentation/care doesn’t reflect standards, there’s a risk of not getting a return.
This was a recent email response to someone in billing asking me why insurance kept sending back the NP’s paperwork: …When services aren’t getting covered it may be because of the state (if you need a collaborative physician) and if the collab is not signing off on the billable services/medications, it won’t get covered. It may be the actual insurance company; state insurance truly doesn’t cover that much. If you continue to have issues with billing you may want to consider switching to cash/credit options. Here’s another secret, sometimes I’ll call the insurance company and actually speak to someone about how things are not getting covered and what to do about it… sometimes it’s a misunderstanding etc. or the clinical note isn’t sufficient to bill for the services.
My collaborative physician is not literally working in the office with me, but I need the doctor’s information (DEA/NPI) with our EMR for insurance, prescribing, and signing off the documents. The front desk/medical staff also need the information for the prior auths (PAs) and for billing such as how you rank the psych disorders… If you’re charting well, this shouldn’t be a train wreck where people are constantly bothering you about what needs to be added, corrected, etc.
Lastly, before I go into the formats, I’ve seen and found many different kinds that were acceptable for billing but for me (or you) –stick to what will help you the most. Like my collab said, “I can’t help but to write in sentences because I’ve been taught to write sentences” lol and that’s right! I learn, read, memorized, write, and talk in SENTENCES so writing a narrative is the easiest for me but I’ll show the alternative as examples as well.
Just to be clear an outline/checkbox format is simply just a “narrative” without sentences. I took out the “checkboxes” below just to make it easier to view and tailor online. Overall, I recommend copying/pasting the information into another document (I use google docs) and tailoring it to your own liking or whatever is the most convenient. I also feel like people need to understand the burden of charting in psych so they know what they’re getting into schools/professors/providers let them KNOW! and here we go:
My General (Narrative) Intake
- Pros: best format for complicated patients and special populations, most accurate and clear
- Cons: least time-efficient, focused on the past, the bigger picture, and everything between -some people may think it’s too much unnecessary added information but that’s how it is in CMH…
Chief Complaint: “what is the reason why the patient/client is present” I usually put if the eval was in-person vs telehealth, first/last name, age, ethnicity, and pertinent current information; a lack of sleep, appetite, etc.
Problem 1, Plan: problem (my diagnosis), plan: the medication, and education about the med or educating about ETOH cessation.
Rating Scales: PHQ/GAD (screening tool) results or they can just be uploaded in the EMR…
History of Present Illness: I usually put the 1st encounter with the patient. The history of the issues, c/c, and pertinent past information; SI attempts or witnessing SI, HI, or other trauma.
Developmental Hx: the product of vaginal/c-section birth, FT (full-term) or 36 weeks, +any issues with birth, milestones, ACES, highest grade completed…
Past Psychiatric History: hx of inpatient, hospitalizations, the reason, outcomes, etc.
ROS: any other problems today? at least cover neuro, resp, skin, cardiac, GI
Med/Surg: past/current medical and surgical information, allergies, height/weight
LMP: birth ctrl methods and the hx of menses; heavy, irregular, painful, PMS?
Current Medications: psych and medical; Past RX; medication (reasons for d/c)
Scheduled Opioid Report: no conflicts, prescription hx consistent
Family History: psych and substance abuse, pertinent medical i.e. DM, CA, or heart disease
Past, Family, and/or Social History (PFSH) An age-appropriate review of past and current activities… (ACC.org) -pertinent for state insurance billing. who the patient lives with, job, housing, current school, or activities, safety risks such as homelessness, domestic issues, etc.
Substance Abuse History: (current or past use, hx of rehab/OD) ETOH, cigarettes, substances
Legal: current or past legal issues
Mental Status Exam: appearance, tone/rate/content of speech, eye contact, orientation
Impression: what and why this diagnosis was given, stability (written here or above with problems), and possible rule-outs.
Plan: conclusion of this meeting and what’s the plan for the next meeting…
Documentation (Narrative Examples)
Stable: Tolerable Issues, Mood/Conditions Balanced, Maintenance
CC: follow-up in-person/office. JB is a 23 y/o WM reports no issues with mood or medications, “I feel fine”. No concern with sleep or appetite denies thoughts or intent to harm self or others, denies AVH (audible/visual hallucinations). Agreed to f/u within 4 weeks. Reports no additional concerns.
- Problem 1 GAD: JB feels more anxious in the morning. Plan: increase sertraline dose to 50mg BID. (problems prioritized or ranked just like with billing)
- Problem 2 ADHD…
HPI: last encounter with patient was 3/3/22. Pt. has a hx of GAD, ADHD and discussed decreasing quetiapine to 50mg from 100mg r/t grogginess. Pt. was on this dose for 3 years but report not having as severe sleep problems as previously mentioned. No prior medications or hospitalizations related to mental health or SI.
ROS: Neuro- denies dizziness, headaches, denies syncope, seizures. GI- no N/V/D, abdominal pain, constipation. SKIN: denies rash, swelling, Psych- no SI, HI, AH, VH.
MEDICATIONS: sometimes automatically generated in the EMR
PMP Score: 0 conflicts
Med/Surg: denies, 5’11 #189. NKDA
PFSH: patient lives alone, and started working at Costco, afternoon shift.
MSE: JB continues to be cooperative and adheres to treatment. Good insight to needs and strengths. Aware of improving coping skills. Thought content was with no psychotic or suicidal thoughts. John was cooperative, well-groomed, good eye contact. Communicates needs appropriately. Thought content was with no psychotic, suicidal, or harmful thoughts.
PLAN:
- Adhere to treatment/medication/therapy -I usually just say “treatment” to cover everything
- Encourage ETOH cessation (or whatever lifestyle behavior/changes that were discussed)
- Medication changes (if any): it could be placed here and/or in the CC
- RTC (return to clinic) within 4 weeks or sooner for concerns or seek immediate assistance
Unstable: SI, HI, Psychosis, Manic, Aggressive, Unpredictable
CC: follow-up completed in the office. AH is a 37y/o who reports being pregnant and “seeing shadows and bugs” for the last couple of days. HX of BPI, DM, HTN, GAD, MDD. She’s currently in an abusive relationship but her partner is the “only support system”. AH reports she has been getting “angrier” and “deserves to be hit in the head”. AH reports the last time she was assaulted was the past weekend and has been hallucinating since. Expressed not wanting to report the incident because she had +LOC, and doesn’t remember what happened, “I don’t want to make anything worse”. She hasn’t seen the OB since the positive pregnancy and hasn’t been taking prenatals “I feel too overwhelmed”. Reports taking her medications off/on (or not adhering with treatment) and worried about relapsing on heroin. Endorsing hallucinations but r/o possible head injury. Agreed to f/u <2 weeks.
- Problem 1 BP1 (unstable): AH hasn’t been taking her cariprazine (Vraylar) and her behaviors are becoming more riskier. Plan: collaborate with OB, confirm the pregnancy, and inquire about restarting medications and possibly adding Suboxone.
- Problem 2 GAD…
- Problem 3 MDD…
Rating Scales: n/a due to ruling out hallucinations
HPI: last encounter with patient was 3/3/22. AH adherence with medications and treatment is off/on. Sometimes unreliable hx due to difficult memory and moods. Past aggressive behaviors include yelling and pacing. Limited social support and was homeless last year due to losing employment and substance abuse. Hx of impulsivities, BP1, GAD, MDD, Opioid Abuse. Hospitalized x3 for OD and SI >5 years ago, unsure of dates, locations, or treatment. Past hx of drug-induced hallucinations but it also occurs with increased stress. Denies rehab hx, and reports getting sober for her youngest child but he was raised by other family members and she relapsed multiple times. Last use of [substance(s)] was 12/2021.
ROS: headache off/on, +n/v r/t “pregnancy”, feet swelling, -dizzy, no chest pain, -SOB uses an inhaler as needed for anxiety
Med/Surg: NKDA HTN, cholesterol, DM, back surg Dec/2020. 5’4, #210. Medications: Lisinopril, Metformin, Albuterol. NKDA
PFSH: lives with boyfriend and 4y/o son, collects SSD
MSE: AH was cooperative but restless, and paranoid throughout the meeting. Communicate concerns and issues appropriately. Low insight, aware of the concern with impulses and relapsing. Thought content with no suicidal thoughts but possible AVH.
PLAN:
- Encouraged to adhere with treatment and therapy
- Developed a safety plan with social services
- Consent with sharing information with OB/PCP/etc.
- Consult with Case Management
- RX test next meeting
- RTC 2 weeks or sooner for concerns or seek ER services
-sidenote, if this was one of my real narratives (which isn’t that much different) it’ll seriously be longer but for the sake of this post, I just wanted to quickly showcase how the flow of the charting will go and with charting “complicated cases”, the MORE the merrier…This is also how you justify 99214-99215s.
I probably need to make another post about “aggression” or “crises” documentation itself so below are just standard phrases/formats for general outpatient settings –more than likely, I’ll add more in the respective areas:
Narrative Format Part 2
Chief Complaint (symptom, problem, condition, diagnosis):
HPI History (HPI, review of systems, PFSH):
Medical Comorbidity (current status)
Allergies:
Medical/Surgical HX:
Family HX:
Past Psych HX
Substance Abuse:
MSE:
DEVELOPMENTAL HISTORY:
EDUCATIONAL HISTORY:
SOCIAL HISTORY:
LEGAL HISTORY:
Narrative Format Part 3
Pertinent HX:
HPI:
ROS:
Psych HX:
Prior Meds:
Family HX:
Father:
Mother:
Siblings/Other (grandparents, child):
Developmental HX:
Legal: denies current probation, warrants, or court dates.
Substance HX:
Non-Psychiatric Medical/Surgical History/Allergies:
Educational HX:
Personal HX:
Mental Status Examination Narrative:
Summary of Findings/Biopsychosocial Formulation:
Assessment of Risk Factors:
Summary and Treatment Recommendations:
Projected Length of Treatment:
Prognosis:
Discharge Criteria:
Progress/Follow-up Narrative Formate
-Please note how you can just add from the intake (or the previous note) in the respective areas and tweak the information to reflect current changes, so charting should be easier moving forward…
- CC: rating scales can be done q3-6months after intake
- HPI
- PFSH
- ROS
- MSE
- Problem/Condition: New/Established, Improve/Worsening, Co-Morbities; stable, complications/side-effects, independent or additional assistance required, interference with the primary problem
- PLAN
An Outlined/Checkbox Intake
- Pros: great for follow-ups, high caseloads, and low acuity patients, the most practical
- Cons: vague, not detailed so it can be confusing or inadequate charting
Format 1
CC:
HPI:
Family HX: father, mother, siblings, extended -(psych hx & notes)
Personal & Social:
Gestation and Birth:
- Intrauterine Exposures: none, alcohol, tobacco, psychotropic medications, others: exposures were: Term, Preterm
- Delivery: Normal, Spontaneous, Induced, Vaginal Delivery, C-section, Forceps Delivery
- Birth Complications: none, breach, nuchal cord, anoxia, apnea, abnormal APGAR, jaundice, meconium aspiration
Early Development and Health:
- Developmental Milestones: Early, Normal, Delayed, healthy childhood, significant for:
Childhood Family Social Position and Home Atmosphere:
- Normal, Supportive, Parental Fighting, Parental Violence, Financial Difficulties, Frequent Moving
Childhood Behavior Symptoms:
- Tantrums, Enuresis, Encopresis, Running Away from Home, Fighting, Truancy, School Refusal, Suspensions, Expulsions, Stealing, Property Damage, Fire-Setting, Animal Cruelty
School/Education:
- School phobia, Fighting, Detentions, Expulsions, Class Failures, Repetition of Grades, Special Education, Remedial Classes, Speech Classes, Tutoring, Accommodations
- HS graduate, Bachelor’s Degree, Master’s Degree, MBA, Ph.D., Law Degree, MD Degree
- Standardized Test Performance:
Occupations:
- Employed, Unemployed, Retired, Disability
- Longest Employment:
- Longest Unemployment:
Living Situations:
- Alone, Roommates, Family, Group Home, Homeless
Menstrual and Sexual History:
- Menses beginning at age:
- Premenstrual symptoms: dysphoria, cramps, appetite change, bloating, sleep disturbance, Pregnancies, Miscarriages, Abortions
- Orientation: Heterosexual, Homosexual, Bisexual, Other:
Abuse History:
- Sexual Abuse, Physical Abuse, Verbal Abuse, non-confidentiality warning given
- none:
- history of abuse by:
- type of abuse:
- Report: not applicable, –or made to:
Relationships:
- Single, Relationship, Never Married, Married, Partnered, Divorced, Widowed
- Longest Relationship:
- Extramarital Affairs:
- Current relationship (name, length):
- Never married
- First married at age:
- Total number of marriages:
- Divorced/reason for divorce(s):
Children: (note ages, custody, psychiatric problems, substance abuse)
Legal:
Religious/Spiritual:
Substance Abuse History:
- Substance
- Age of Onset
- Current Amount Used and Frequency (with time period identified)
- Last Used
- Maximum Amount Used and Frequency (with time period identified)
- Longest Duration of Abstinence (with time period identified)
- Abstinence Symptoms
- CAGE SCORE:
- History of Detoxification/Rehabilitation Programs (inpatient/outpatient, AA/NA):
- How are substances financed/obtained?:
- Substance-Related Legal Issues (including DWI/DUI):
- Tobacco Use:
- Caffeine Use:
Medical History
- Medical Issues:
- Surgical History:
- Allergies:
- Current Medications:
- Outpatient Primary Care Provider with Contact Number:
- Last Visit:
- Last Laboratory Work/EKG:
Medical ROS:
Past Psych HX:
- Psychiatric History (age of onset, symptoms, diagnoses):
- History of Neuroimaging:
- History of EEG/Functional Imagining:
- History of Lost of Consciousness/Traumatic Brain Injury/Concussions:
- Psychiatric History (age of onset, symptoms, diagnoses):
- History of Neuroimaging:
- History of EEG/Functional Imagining:
- History of Lost of Consciousness/Traumatic Brain Injury/Concussions:
- History of Neuropsychological Testing:
- Past Psychiatric Hospitalizations (dates, locations, diagnoses, treatments, disposition):
- Past Treatments (specifics of medication, ECT):
- Self-Injurious Behavior:
- Violence:
- Current Outpatient Mental Health Providers and Contact Numbers:
MSE:
Physical Exam: vitals, etc.
Plan:
Outlined Format Follow-Up/Progress Notes
CC: “I am having less stress”
HPI: 24 y/o hx of GAD and MDD. Needs to go to work soon, no issues with medications, hydroxyzine “helps”
Stressors (medical/family/relationship/financial/employment/educational/housing): works in an HS, lives with girlfriend
Mood: “overwhelmed”
Sleep: 7 hours off/on
Appetite: no issues
Psychomotor: denies agitation or slowing
Use of PRNS: propanolol QD
Impulsivity: denies
Drug/ETOH/Substance: denies
Scheduled Reports: 0 issues
AIMS: Denies any abnormal movement
ROS: negative per pt self-report
Impression: condition is stable but still feel overwhelmed despite regular use of prescribed medications.
DX: MDD, GAD rule out PTSD
Plan: Continue propanolol, consider the addition of buspirone, RTC 4 weeks
Different ROS Formats
Constitutional: no fever, weight, loss or gain, anorexia, fatigue
Eyes: no double vision or blurry vision
ENT: no tinnitus, dry mouth
Cardiovascular: no fainting/palpitations or other cardiac problems.
Respiratory: no SOB, DIB
GI: no constipation or diarrhea
GU: no urinary hesitation, incontinence
Musculoskeletal: no muscle twitches, chronic pain
Skin: no rash, lesions, psoriasis, pruritus
Neurological: no ataxia, tremor, vertigo, headache
Heme/lymph: no easy bruising or bleeding
Endocrine: no polyuria, polydipsia, heat or cold intolerance
Allergy/Immunology: no hives
Psychiatric: see above for positives
GEN: (+)cooperative with exam, (+)well-groomed, (+)well developed, (+)well-nourished, (+)overweight, (+)obese, (+)morbidly obese, (+)emaciated, (+)appears to be stated age, (+)appears older than stated age, (+)appears younger than stated age
HEART/RESP: denies DIB, chest discomfort
GI: denies n/v/d, GI pain
NEURO: normal gait and station, normal gait, normal station
PSYCH: alert and oriented to time, place, and person, normal mood, normal affect
GENERAL: Denies weakness, fatigue, malaise, chills, fever, night sweats, weight gain/loss
INTEGUMENTARY: Denies rash, jaundice or other skin issues
NEUROLOGIC: Denies headaches, weakness, tremors or syncopal episodes or seizures
HEENT: Denies tinnitus, vertigo, visual changes, hearing impairment, sore throat
CARDIOVASCULAR: Denies chest pain palpitations, negative edema.
RESPIRATORY: Denies any shortness of breath, asthma, OSA
GASTROINTESTINAL: Denies dysphagia, nausea, vomiting, hematemesis, or abdominal pain.
GENITOURINARY: Denies increased frequency, urgency, dysuria, incontinence.
MUSCULOSKELETAL: joint pain, stiffness, weakness, or back pain
PSYCHIATRIC: no acute issues
ROS negative for fever, cough, sob, pain
PSYCHIATRIC ROS
No Anxiety/Panic, No Depression, No Insomnia, No Personality Changes, No Delusions, No Rumination, No SI/HI/AH/VH, No Social Issues, No Memory Changes, No Violence/Abuse Hx., No Eating Concerns
Major depressive/dysthymic symptoms
Manic or hypomanic symptom
Psychotic symptoms
Generalized anxiety disorder
Panic disorder
Obsessive-compulsive disorder
Dementias
Eating disorders
Dissociative disorders
PTSD
Systems Reviewed Below with Pertinent Positives/Negatives if Clinically Indicated:
Constitutional: No Weight Change, No Fever, No Chills, No Night Sweats, No Fatigue, No Malaise
ENT/Mouth: No Hearing Changes, No Ear Pain, No Nasal Congestion, No Sinus Pain, No Hoarseness, No sore throat, No Rhinorrhea, No Swallowing Difficulty
Eyes: No Eye Pain, No Swelling, No Redness, No Foreign Body, No Discharge, No Vision Changes
Cardiovascular: No Chest Pain, No SOB, No PND, No Dyspnea on Exertion, No Orthopnea, No Claudication, No Edema, No Palpitations
Respiratory: No Cough, No Sputum, No Wheezing, No Smoke Exposure, No Dyspnea
Gastrointestinal: No Nausea, No Vomiting, No Diarrhea, No Constipation, No Pain, No Heartburn, No Anorexia, No Dysphagia, No Hematochezia, No Melena, No Flatulence, No Jaundice
Genitourinary: No Dysmenorrhea, No DUB, No Dyspareunia, No Dysuria, No Urinary Frequency, No Hematuria, No Urinary Incontinence, No Urgency, No Flank Pain, No Urinary Flow Changes, No Hesitancy
Musculoskeletal: No Arthralgias, No Myalgias, No Joint Swelling, No Joint Stiffness, No Back Pain, No Neck Pain, No Injury History
Skin: No Skin Lesions, No Pruritis, No Hair Changes, No Breast/Skin Changes, No Nipple Discharge
AIMS
AIMS: all 0’s or none (0=None to 4=Severe)
Muscles of Facial Expression
Lips and Perioral Area (puckering, smacking, pouting)
Jaw (biting, chewing, lateral movement, mouth opening)
Tongue (increase in movement both in and out of mouth)
Upper Extremity (choreic or athetoid movements, does not include tremors)
Lower Extremity (tapping, squirming)
Trunk Movements (rocking, twisting, squirming)
Overall Severity
Incapacitation due to abnormal movements
Patient’s awareness of abnormal movements
MSE
Answers and communicates appropriately, proper temperament, and cooperative. Has moderate insight into actions and consequences. Capable of communicating appropriately and following instructions. Behavior and mood is consistent. Client is able-bodied without learning disabilities. No obvious/major concerns or distress. Patient is able-bodied but uncooperative with family, treatment, and following instructions. Needs to be more engaging with care and accountability. Poor insight with consequences of actions or how to control anger and behaviors.
The patient’s speech and tone was normal. Thought processes were logical, relevant, and thoughts were completed normally. Thought content was normal. Thought content was normal with no psychotic or suicidal thoughts. The patient’s judgment was realistic with normal insight into their present condition. Mental status included: correct time, place, person orientation, normal recent and remote memory, normal attention span and concentration ability. Language skills included the ability to correctly name objects. Fund of knowledge included normal awareness of current and past events.
The patient’s speech was normal, sharing conversation with normal laryngeal efforts. Appropriate mood and affect were seen on the exam. Thought processes were logical, relevant, and thoughts were completed normally. Thought content was normal with no psychotic or suicidal thoughts. The patient’s judgment was realistic with normal insight into their present condition. Mental status included: correct time, place, person orientation, normal recent and remote memory, normal attention span and concentration ability. Fund of knowledge included normal awareness of current and past events. Emotionally the patient appeared alert. Attitude in the interview consisted of cooperation. the effect was depressed. Speech was normal and calm. Appropriate mood and affect were seen on the exam. Thought processes were logical and relevant with no psychotic or suicidal thoughts. The patient’s judgment was realistic with fair insight into her present condition but continues to have impulsive patterns.
Appearance: Well-groomed, well dressed, well-nourished
Behavior: Cooperative, calm, pleasant, consistent eye contact
Speech: Clear, spontaneous, regular rate, rhythm, and volume
Mood: stable, content, down-casted
Affect: full-range, congruent to mood
Thought Process: goal-directed, logical, linear, organized
Thought Content: denies SI/HI, denies AH/VH, denies delusions, denies intrusive thoughts
Sensorium: person, place, time/date & situation
Cognition: grossly intact
Insight: Good as evidenced by the recognition of symptoms needing tx
Judgment:
Documentation for Conditions/Symptoms
These options of symptoms can go into the documented “psych problems 1,2,3, etc.” EX. Problem 1 anxiety; Michael continues to have excessive worrying and panic attacks. Plan: increase fluoxetine BID and encourage marijuana cessation. Symptoms can also go into the chief complaint and/or the “impression” of diagnosis category…
- ADHD: Inattention:1) fails to give close attention to details/makes careless mistakes in school/work/activity. 2) difficulty sustaining attention in task or play, 3) does not seem to listen when spoken to,4) does not follow through on instructions and fails to finish work/duties, 5) difficulty organizing tasks/activities, 6) avoids, dislikes, is reluctant to engage in tasks that require sustained mental effort, 7) loses things necessary for tasks or activities, 8) easily distracted by extraneous stimuli, 9) forgetful in daily activities Hyperactivity: 1) fidget/squirms, 2) leaves situation when remaining seated is expected, 3) feelings of restlessness, 4) difficulty in engaging in leisure activities quietly, 5) often on the go or acts as if driven by a motor, 6) talks excessively Impulsivity: 1) blurts our answers before questions completed, 2) difficulty waiting turn, 3) interrupts/intrudes on others.
- Anxiety: anxiety, nervousness, excessive worrying, specific phobias, panic attacks (sudden fear/going to die), agoraphobia, repeated behaviors, impulsive, interference with ADLS…
- Borderline PD: identity problems, moodiness, emptiness, suicidal feelings, paranoia, dissociative sx, abandonment fears, impulsivity, rage, relationship instability, doctor shopping, lawsuits against MD’s, immediate idealization, excessive interest in your personal life
- Depersonalization/Derealization, etc. (Dissociative Disorders): memory loss (amnesia) of certain time periods, events, people, and personal information, a sense of being detached from yourself and your emotions, a perception of the people and things around you as distorted and unreal, a blurred sense of identity, significant stress or problems in your relationships, work or other important areas of your life, inability to cope well with emotional or professional stress
- Depression: sad, irritable, suicidal thoughts, homicidal thoughts, poor sleep, poor energy, poor concentration, poor appetite, weight changes, anhedonia, worthlessness, hopelessness, helplessness, psychomotor agitation, psychomotor retardation
- Eating Disorders: feeling overweight/underweight, fear of fatness. dieted, laxative use, purging behavior, bingeing history
- Mania: elevated mood, increased energy, grandiosity, racing thoughts, pressured speech, distractability, increased goal-directed behavior, decreased need for sleep, hypersexuality, poor judgment, flight of ideas
- Psychosis: auditory hallucinations, visual hallucination, olfactory hallucinations, gustatory/tactile hallucinations, delusional beliefs (paranoia, ideas of reference, thought-broadcasting, thought insertion) loose association, thought disorder
- PTSD: Exposed to a traumatic event, response involved fear, helplessness…Reexperienced: 1) rec, intrusive thoughts 2) rec dreams 3) feeling like it is happening again 4) psychological distress at exposure, cues 5) physiologic response to cues Avoidance: 1) Avoid thoughts, feelings assoc w event 2) Avoid act. that arouse recollection 3) inability to recall imp parts of trauma 4) decreased interest in activities 5) detachment 6) restricted range of effect 7) sense of foreshortened future Arousal: 1) diff sleeping 2) irritability, outbursts 3) diff concentrating 4) hypervigilance 5) exaggerated startle
- Sleep: Difficulty falling asleep, broken sleep, early morning awakening, snoring, night terrors, vivid dreams, napping, narcolepsy
- Substance Abuse: unable cut-down, annoyed by concern, guilt, eye-opener, impulsive/binge patterns
Documentation for Educating about Medications
I usually edit these into dx/problem/plan area as what was discussed or patient education and/or the patient’s response…
Antidepressants: discussed s/e including GI, sexual dysfunction, headache, anxiety, dizziness, dry mouth, and insomnia. Commonly shared side effects (often dose-related) include abdominal pain, constipation, diarrhea, dyspepsia, nausea, and vomiting. An uncommon, but potentially serious side-effect is serotonin syndrome. Due to the increased risk of suicidality with antidepressants, patients and their family members or caregivers were instructed to immediately report any sudden changes in mood, behaviors, thoughts, or feelings.
Atypical Antipsychotics-we discussed risks of atypical antipsychotic use including side effects, benefits, and alternatives of the medication and the client was offered patient education material. The client understands the need for periodic lab testing with the possibility of the medicine increasing serum glucose and lipids. They also verbalize understanding the other possible metabolic abnormalities that could result from the medicine including weight gain as well as the need to eat a proper diet and get exercise as tolerated. The client verbalizes understanding that the medication can also cause dyskinesias including tardive dyskinesia (uncontrollable movements of the face, torso, limbs, finger and/or toes) and is advise to monitor for signs/symptoms of neuroleptic malignant syndrome including but not limited to fever, confusion, muscular rigidity, variable blood pressure, sweating, and tachycardia.
Bupropion: discussed common s/e of bupropion: agitation, anxiety, constipation, dryness of mouth. Rare S/E includes: ringing in ear, fast or slow heartbeat, muscle pain. Very rare s/e, but potentially life-threatening: Seizures –increases in patient with a history of seizures, head trauma, CNS tumor, abrupt discontinuation of sedative-hypnotics or ethanol. Confusion, hallucination Black box warning–Suicidal Ideation
Benzodiazepienes: BZs are meant for short-term or intermittent use due to their long term-risks, including physical dependence. BZs have a black box warning for risks when combined with opioids and the risks of abuse, addiction, physical dependence, and withdrawal. Serious risks: injuries/falls/broken bones,car accidents (legally considered a DUI), breathing problems, suicidal/violent thoughts, overdose/overdose death. Long-term risks: memory loss, osteoporosis, tolerance, physical dependence, withdrawal symptoms, addiction, For Women: Taking BZs while pregnant carries a risk of miscarriage and can cause risk to the newborn– including breathing and breastfeeding problems, flaccid muscles, and withdrawal syndrome. For Elderly: Patients over age 65 have an especially high risk of side effects like falls, fractures, and problems with thinking and memory, partly due to slower metabolism of the drug from aging. You should not combine this medication with alcohol, Z-drugs (such as Ambien or Lunesta), other BZs, opioids, or any other drug that causes sedation like gabapentin. Doing so can put me at risk of overdose and death due to combined effects on breathing.
Benzodiazepines: discussed the risks including side effects (amnesia, confusion, GI disturbances, falls, blurred or double vision, long-term use may be linked to increased risk of Alzheimer’s disease), benefits, and alternatives of benzodiazepine use and the client was offered patient education material. We discussed that these types of medications may be potentially addictive and they should not share with others, let other people know they are taking them, or take extra doses beyond what is prescribed. The client verbalizes understanding the medications will not be refilled early. The client verbalizes understanding they are to avoid alcohol and illicit drug use while taking this medication and should be very cautious when using this medication with other sedating medications. The client verbalizes understanding that they will be cautious and get used to how the medicine makes them feel prior to driving a motor vehicle or engaging in any other activity that could be potentially dangerous due to the possible sedating effects of the medication.
Carbamazepine (Tegretol)-female patients-We discussed the risks, including side effects, benefits, and alternatives of Tegretol and the client was offered patient education material. We discussed how Tegretol can affect the hepatic, hematologic, and dermatologic systems of the body. The client verbalizes understanding on how to recognize the signs and symptoms of dysfunction in those areas including but not limited to rash, unusual bleeding/bruising, mouth sores, infections, sore throat, purpura, and sedation. The client is advised about the need for periodic lab monitoring to assess the Tegretol level as well as liver function and complete blood count. We also discussed how Tegretol can interfere with certain types of hormonal contraception and how the client should have a form of barrier type contraception or practice abstinence to prevent getting pregnant because of the risk of teratogenic effects.
Carbamazepine (Tegretol)-male patients-We discussed the risks, including side effects, benefits, and alternatives of Tegretol and the client was offered patient education material. We discussed how Tegretol can affect the hepatic, hematologic, and dermatologic systems of the body. The client verbalizes understanding on how to recognize the signs and symptoms of dysfunction in those areas including but not limited to rash, unusual bleeding/bruising, mouth sores, infections, sore throat, purpura, and sedation. The client is advised about the need for periodic lab monitoring to assess the Tegretol level as well as liver function and complete blood count.
Depakote– discussed the risks including side effects (including but not limited to sedation, tremor, dizziness, GI upset, headache, weight gain, alopecia, tachycardia or bradycardia), benefits, and alternatives of Depakote and client was offered patient education material. We discussed how Depakote can have effects on hematologic (easy bruising, excessive bleeding), pancreatic (pancreatitis-abdominal pain, nausea, vomiting, anorexia), hepatic (malaise, weakness, lethargy, facial edema, anorexia, vomiting, jaundice), and dermatologic (jaundice, alopecia) systems. The client knows how to watch for signs of dysfunction in those areas. They are also advised of periodic lab testing to assess the Depakote level, liver function, and blood counts. The client verbalized understanding to watch for signs and symptoms of rash with Depakote use and is advised if rash occurs they are to notify primary care provider or emergency department immediately.
Lamotrigine: patient advised of the risk of possibly fatal rash (i.e., Stevens-Johnson Syndrome) and agrees to stop medication, and seek medical attention immediately if any rash or rash or blistering of the mucosal surfaces develop given the potential for lethality and requirement for evaluation by a physician to rule this out. The patient further advised that the risk of this reaction increases if proper dose titration is not adhered to carefully and that not taking this medication for 2 days or more will require a retitration process, and, therefore the patient should not restart at the previous dose, but call me immediately for instructions on how to retitrate.
Lamotrigine-We discussed the risks including side effects, benefits, and alternatives of Lamictal and the client was offered educational material. We reviewed the need for a titration schedule with Lamictal because of possibility of increased incidence of rash, both benign and severe, when starting the Lamictal at higher doses and increasing it more quickly. The client verbalizes understanding of the possibility of a serious rash including Stevens-Johnson syndrome as a result of taking the medication. They are advised to stop taking the medication and contact the clinic if they are experiencing these symptoms. They are advised to go to the emergency room if they develop signs of more severe rash including but not limited to painful red or purplish rash, spreading of rash, blister formation on skin and/or mucous membranes of the mouth, nose, eyes, and/or genitals, shedding of skin, facial swelling, and/or swollen lips.
Lithium-We discussed the risks, including side effects (including but not limited to weight gain, hair loss, memory problems, irregular heartbeat or pulse, fatigue, and decreased thyroid function), benefits, and alternatives of Lithium. The client was offered educational material. We discussed how lithium can have effects on the kidneys and thyroid functioning and we discussed how to recognize signs in symptoms in those areas. The client verbalizes understanding the need to stay well hydrated as well as the need for periodic lab testing to monitor lithium levels. We discussed some of the prescriptions and over-the-counter medications to avoid when taking lithium. The client verbalizes understanding how to recognize signs of increased lithium levels including lithium toxicity including but not limited to tremors, thirst, diuresis, diarrhea, vomiting, drowsiness, muscle weakness, coordination problems, blurred vision, tinnitus, slurred speech, and decreased LOC.
Pregnancy– discussed that some medications can have effects on pregnancy and some can cause teratogenic results. I recommend the client strongly consider the use of family planning methods including contraceptives or other forms of birth control. We discussed that if the client is planning to get pregnant that a discussion needs to be held of what to do with medications and other treatments. I do recommend that the client take supplemental folic acid to prevent birth defects in any case.
Mirtazapine (Remeron)– discussed the risks including side effects, benefits, and alternatives of mirtazapine, and the client was offered educational material. The client verbalizes understanding that the use of mirtazapine strictly for sleep or anxiety is considered off-label however that it also can confer some extra antidepressant effect in any case.
Serotonin Syndrome– discussed how these medications target the neurotransmitter serotonin. We discussed that taking medications that affect this chemical can have an increased risk for too much of the chemical resulting in serotonin syndrome. The client verbalizes understanding the signs and symptoms associated with this disorder including but not limited to rapid/irregular heartbeat, shakiness, hallucinations, blood pressure fluctuations, increased agitation, mental status changes, fever, dilated pupils, and muscle rigidity. Patient is advised to seek immediate medical attention if these symptoms occur.
Sleep Medication-We discussed the risks including side effects, benefits, and alternatives of utilizing medication indicated for sleep including sleep hygiene recommendations including but not limited to avoiding screen time one hour prior to bed, minimizing caffeine, nicotine and alcohol intake, sticking to a sleep schedule, daily exercise, avoiding large meals and/or beverages prior to bed, relaxation activities prior to bed, and maintaining a good sleep environment. We reviewed that sleep medications can cause drowsiness the next morning and they should be careful when operating machinery or other tasks that require sustained attention. The client also verbalizes understanding that sleep medications can cause parasomnias including sleep driving. The client is also advised to use other medications that cause sedation with extreme caution.
Stimulant Risks
- Denies family history of unexplained sudden death of less than 30 years.
- Denies family history or personal history of heart disease.
- Denies family history or personal history of chest pain, palpitations, or fainting during exertion.
- Denies history of dizziness while exercising.
- Denies family history or personal history of prolonged QT Syndrome.
Stimulant Education
Stimulants and related medications are generally well-tolerated and safe although there are no long-term studies on safety with adult treatment. The most common adverse reactions to stimulants and related medications are loss of appetite, upset stomach, insomnia, and headache. Increases in heart rate and blood pressure have also been seen as a result of the sympathomimetic properties of stimulant medications. Serious risks include:
- Cardiovascular events such as stroke, MI, death
- Peripheral Vasculopathy, Including Raynaud’s Phenomenon
- Risk of Priapism with Methylphenidate Products
- Rhabdomyolysis with Stimulant Drugs
- Risk of Psychiatric Adverse Events such as psychosis, SI and mania
- Abuse and Misuse of Stimulant Medications
- Significant abuse potential
Stimulants-We discussed the risks including side effects, benefits, and alternatives of stimulant medication use and the client was offered patient education material. We talked about the fact that these medications are Schedule II controlled substances as well as the risks of potential addiction. We discussed how this medication will not be refilled early, the medication should not be shared or taken in any manner outside of as prescribed. We discussed the patient should not inform other people she is taking a stimulant. We discussed about the potential for decreased appetite, weight loss, and cardiac effects.
Topiramate (Topamax)-female patients-We discussed the risks including side effects, benefits, and alternatives of Topiramate and client was offered education material. We discussed that while client is taking Toprimate there is the possibility of metabolic acidosis, decrease sweating, fever, increased intraocular pressure as well as kidney stones. The client verbalizes understanding how to stay well hydrated and how to recognize the signs of these potential side effects and what to do if these symptoms occur. Advised client that the use of this medication for this indication is considered off-label. We also discussed how Topiramate can interfere with certain types of hormonal contraception and how the client should have a form of barrier type contraception or practice abstinence to prevent getting pregnant because of the risk of possible teratogenic effects of Topiramate.
Topiramate (Topamax)-male patients– discussed the risks including side effects, benefits, and alternatives of Topiramate, and the client was offered education material. We discussed that while client is taking Toprimate there is the possibility of metabolic acidosis, decrease sweating, fever, increased intraocular pressure as well as kidney stones. The client verbalizes understanding how to stay well hydrated and how to recognize the signs of these potential side effects and what to do if these symptoms occur. Advised client that the use of this medication for this indication is considered off-label.
Trazadone female patients– We discussed the risks including side effects, benefits, and alternatives of Trazadone and the client was offered patient education material. The client verbalizes understanding that the use of Trazadone strictly for sleep or anxiety is considered off-label however that it also can confer some antidepressant effect in any case.
Trazadone male patients– We discussed the risks including side effects, benefits, and alternatives of Trazadone and the client was offered patient education material. We discussed how this medication may cause priapism. The client is advised if they experience this rare but serious side effect they are to seek immediate medical attention. The client verbalizes understanding that the use of Trazadone strictly for sleep or anxiety is considered off-label however that it also can confer some antidepressant effect in any case.
Documentation Kids-Specific
Preschool: frequent unexplained stomachaches, headaches, and fatigue, over activity/excessive restlessness, frequent sadness, low tolerance for frustration, irritability, loss of pleasure in previously enjoyed activities, tendency to portray world as bleak or sad, denies suicidal ideations, no plan or intent, no previous attempts, has support system in place
School-aged: frequent and unexplained physical complaints, low self-esteem, excessive worrying, change in sleep patterns, tearfulness, unprovoked hostility and aggression, school refusal/reluctance, drop in grades, little interest in playing with others, poor communication, thoughts and efforts about running away, morbid/suicidal thoughts, and low tolerance for frustration, denies suicidal ideations, no plan or intent, no previous attempts, has support system in place
Adolescents: drop in grades, behavior problems at school, feelings of sadness and hopelessness, low self-esteem, fatigue, changes in sleep, anhedonia, bad attitude, self-stimulation by smoking/chemical use, self-destructive behavior, difficulty in relationships, eating-related problems, antisocial/delinquent behavior, social isolation, inattention to appearance, extreme sensitivity to rejection or failure, physical slowness/agitation, morbid thoughts, denies suicidal ideations, no plan or intent, no previous attempts, has support system in place.
Moods/Bipolar: mania includes mood swings, elevated mood and irritability, pressured speech and hypertalkative, distractible, increase in goal-directed behavior with no follow-through, excessive involvement/risky behaviors, flight of ideas and racing thoughts, decreased need for sleep, bursts of energy, grandiosity, agitation, increase in activities (spending, sex), psychotic symptoms.
Children: euphoric mood, extreme irritability that is severe and persistent, aggressive episodes and violent behaviors, dysphoric outbursts, intensely emotional with fluctuating but overriding negative mood, ready to go in am, sexually preoccupied.
Childhood Disorders:
- ADHD: poor attention to detail, difficulty sustaining attention in tasks, doesn’t listen, no follow through and poor multitasking, disorganized, avoids attention sustaining activities, loses things easily, forgetful, easily distracted, fidgets, unable to stay in seat, runs about, difficulty sustaining attention at play, on the go, hyper talkative, blurts, interrupts, unable to wait turn.
- ODD: negative attitude, loses temper, defies rules and does not comply with adult requests, deliberately annoys others, blames others, is touchy, angry and resentful, spiteful and vindictive.
- Conduct Disorder: negative attitude, loses temper, defies rules and does not comply with adult requests, deliberately annoys others, blames others, is touchy, angry and resentful, spiteful and vindictive, bullies, threatens or intimidates others, starts fights, has used a weapon to cause physical harm, cruel to animals/people, stoles trivial items, forced sexual activity, destruction of property, fire setting, lies and cons others for gain, stays out late at night <13, run away >2, truant <13.
- PDD: impaired social interaction, poor eye contact, lack of emotional or social reciprocity, lack of spontaneous sharing or interests or enjoyment, communication impairments, repetitive movements, lack of make believe or spontaneous play, restricted interests, inflexible, delays/abnormal functioning in social, language or symbolic or imaginative play.
- RAD-disinhibited type: defused attachment, indiscriminate sociability/excessive familiarity with strangers, lack of selectivity of attachment figures, history of repeated changes in primary caregiver, history of persistent disregard for child’s basic physical and emotional needs.
- RAD-inhibited type: persistent failure to initiate or respond to most social interactions, inhibited, hypervigilant, highly ambivalent and contradictory responses, avoidant, resistant to comforting, history of repeated changes in primary caregiver, history of persistent disregard for child’s basic physical and emotional needs.
SOCIAL COMMUNICATION AND INTERACTION:
- Deficits in social-emotional reciprocity.
- Deficits in nonverbal communicative behaviors used for social interaction.
- Deficits in developing, maintaining, and understanding relationships.
REPETITIVE PATTERNS OF BEHAVIOR / INTERESTS / ACTIVITIES:
- Stereotyped or repetitive motor movements, use of objects, or speech.
- Insistence on sameness, inflexible adherence to routines, or ritualized patterns of
verbal or nonverbal behavior. - Highly restricted, fixated interests that are abnormal in intensity or focus.
- Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of
the environment
Pediatric Intake
CC:
HPI:
Current Medications:
OTC:
Allergies (medications, seasonal, or food):
Past Psychiatric/Past Pertinent History: (refer to PFSH obtained on MM/DD/YYY )
Providers:
Therapist:
Diagnoses:
Medications:
Hospitalizations:
Past suicide attempts:
Past ECT or TMS:
Family Psychiatric/Medical History:
Mental Health:
Substance Abuse:
Medical:
Past Medical History/Medications and Chronic Health Conditions:
Primary Care Provider:
Date of last physical:
Gravida: N/A
Para: N/A
Birth Control: N/A
Denies asthma, seizures, head injuries, headaches, diabetes, HTN, thyroid, or cardiac problems. Past Surgical History:
Previous Hospitalizations:
Previous Head Trauma:
Developmental History: patient is a product of full-term birth, 38 weeks, vaginal/c-section
Non-Contributory. No prenatal exposure to alcohol, tobacco, or drugs. Uncomplicated pregnancy and birth, full term at birth, all developmental milestones met on time. No learning disabilities. Intellectual Functioning is appropriate to patient’s age.
Family/Social/Peer History:
Religious Preference/Spiritual Beliefs/Cultural Preferences:
Education History/Level of Education:
Legal History:
Legal Guardian: None
Legal Offenses: None
History of disability: None
CPS Involvement: None
Abuse History:
Denies physical, emotional, sexual abuse/assault, or domestic violence.
Psychiatric Physical Exam/Mental Status Examination:
Constitutional: Height, weight – vitals as noted on chart
General appearance: well-developed, well-groomed and well-nourished
Musculoskeletal: normal gait, station, muscular strength and tone
Eye Contact:
Rapport:
Mood:
Anxiety:
Affect:
Suicidal Thoughts:
Homicidal Thoughts:
Psychomotor behavior:
Speech: normal rate, rhythm, volume, spontaneity
Judgment:
Insight:
Thought Processes:
Associations:
Psychotic Thoughts: none observed
Obsessions or compulsions: none observed
Alert and oriented x3:
Recent and remote memory: intact
Attentions span and concentration:
Language: normal for naming objects and repetition of phrases
Fund of knowledge: normal for current events, past history, and vocabulary
Review of Systems:
Constitutional: no fever, weight, loss or gain, anorexia, fatigue
Eyes: no double vision or blurry vision
ENT: no tinnitus, dry mouth
Cardiovascular: no fainting/palpitations or other cardiac problems.
Respiratory: no SOB
GI: no constipation or diarrhea
GU: no urinary hesitation, incontinence
Musculoskeletal: no muscle twitches, chronic pain
Skin: no rash, lesions, psoriasis, pruritus
Neurological: no ataxia, tremor, vertigo, headache
Heme/lymph: no easy bruising or bleeding
Endocrine: no polyuria, polydipsia, heat or cold intolerance
Allergy/Immunology: no hives
Psychiatric: see above for positives
Dental Status – Current problems with teeth or dentures?
Comments: none
Status of condition: baseline
Patient’s Strengths and Abilities:
Patient Limitations: current symptoms
Additional Data Reviewed: previous notes
Clinical Goal(s): improve symptoms
Treatment Services:
Pharmacotherapy: After standard cautions were discussed, patient and parents/guardian gave informed consent to start or change the following medication:
Medication Psychoeducation: Discussed and provided
Lab Tests: on Hold
Psychotherapy:
Psychological Evaluation: none
Other Services: None
Referrals to other agencies/services/community support: None at this time
Return to clinic: <4 weeks
Documentation for Safety, Patient Education
A healthy diet and lifestyle were discussed with the patient, the patient requested to routinely follow up with primary care doctor for general medical checkup. The patient is encouraged to refrain from drugs and alcohol for physical mental health. The patient is future-oriented at this point the patient on the phone does not present as grossly psychotic, manic or depressed in regards to her clinical symptoms that would require a higher level of care. Patient encouraged to utilize emergency services ifs she’s experiencing any thoughts of harm to self or anybody else or is experiencing a medical emergency.
Treatment Plan/Recommendations:
- Medication Changes (informed consent was given for current and new medications):
- Labs:
- Referrals:
Education Reviewed with the Patient:
- A treatment plan was reviewed with the patient
- Reviewed risk/benefits, common side effects with the patient including Black Box Warnings (where applicable), and risk of adverse effects and/or death of combining medications with alcohol.
- Discussed risks of medication non-adherence/non-compliance Patient consents to prescribed medications.
- Reinforced physical/emotional benefits of exercise
- Reinforced the negative effect that alcohol use/abuse has on current complaints.
- Risks vs. benefits, as well as side effects with the patient, reviewed alternative treatments, including no treatment discussed, and answered any questions.
I spent a total of (35) minutes on the date of this encounter:
- Meeting with the patient
- Reviewing documentation/coordinating care
- Ordering/Discussing diagnostic results or prior studies
- Need for further testing
- Biopsychosocial Impressions
- Clinical course, Prognosis
- Treatment options, Medication Issues, Risks, and benefits of management options
- Instructions for management and/or follow-up
- Education/counseling
- Supportive psychotherapy
- Post-visit documentation
- Communicating with other medical professionals
Safety Plan: the patient agrees to utilize their available support system as documented above if in emotional distress. If the emotional distress persists, worsens or the patient becomes suicidal, homicidal, or psychotic the patient agrees to contact the appropriate emergency personnel (911) or go to the nearest emergency department if safe to do so.
Documentation about Substance Abuse
Prescription Monitoring Program (OD Risk Score)
- No Opioid Risks: currently no prescribed conflicts or issues, neg history of using opioids or scheduled meds
- Low to Mild risk: patient recently had an opioid filled, but consistently takes medication as prescribed, score:
- Mild-High Risk: patient agreed to weekly dosing and rx testing hx of diversions, score:
- High Risk: the patient doesn’t qualify for a benzodiazepine at this time and agreed to f/u with the pain clinic.
Prognosis
- Favorable with cessation of all illegal substances and adhering to medication, treatment, and social services.
- Favorable with cessation of illegal substances and adhering to medication, treatment, and improving social services and support.
- Low to favorable with cessation of poly substances and improving social support and adhering with therapy and treatment.
- Mild to favorable with complete cessation of ETOH, therapy, and adhering with treatment and medications.
- Poor to favorable with complete cessation of ETOH, therapy, and adhering with treatment and medications.
Risk factors including age, gender, substance use, lack of medication compliance, intoxication, homelessness, and poor support, can disinhibit patients and can lead to chronically elevated risk of impulsive behaviors including overdose, accidental and or intentional, and suicide attempts. The current risk for violence toward self or others at this time is low. The patient has been compliant with treatment, not engaging in substance use, no recent thoughts or attempts for SI or HI
Documentation for Telehealth
This telehealth patient encounter was conducted via secure, live, face-to-face video conferencing with the patient. This visit was conducted via telehealth instead of face-to-face because of the risk of COVID-19 exposure inherent in being physically present in the company of others.
- Patient’s location during the encounter:
- Demographics and emergency contact names and telephone numbers are up to date:
- Emergency plan: In the event of an emergency, the provider may ask the patient and/or family member/caregiver to contact 911. If it is not possible for the patient or someone at their location to contact 911, the provider will contact 911 and provide the patient’s location. The patient was informed of this safety plan and verbally consented to it.
MSE (with parent alone/without child): N/A visit completed via telehealth with parent/guardian alone. Denies additional concerns or distress.
MENTAL STATUS EXAM with Patient Present on Video:
General Appearance: well-groomed/Bizzare/inappropriate/poor/casually dressed, fair grooming
Gait: cannot assess via video
Station: cannot assess via video
Abnormal Movements: none; no tics
Speech: normal/low/soft volume, short answers, and often does not answer
Mood: “I don’t know”
Affect: congruent/impaired/hard to see as the patient frequently moves out of the frame
Eye Contact: good/mild/fair/poor/cannot assess via telehealth
Thought Process: intact/hard to assess given limited speech
Associations: intact/hard to assess given limited speech
Thought Content: No evidence of responding to internal stimuli
Suicidal Ideation: denies
Violent Ideation: None reported
Memory: not formally assessed, grossly intact
Attention: Intact/Delayed/Impaired
Language: wnl for age
Fund of Knowledge: not formally tested; grossly wnl for age
Insight: Good/Fair/Impaired
Judgment: Intact/Impaired
Additional References & Information
Proper documentation is critical to justifying medical necessity and selection of codes for billing. It tells the story of a patient visit by recording pertinent facts, findings and observations. Payers will use this documentation to verify coding choices, site of service, medical necessity, appropriateness and accurate reporting of furnished services. Each office note must tell a complete story and be able to stand alone. For example, auditors interested in services provided on Aug. 18, 2019 will only review that note; they will not look at notes from other visits unless they are referenced in your note from Aug. 18, 2019. -Links for proper documentation –American College of Cardiology/ACC
