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psych soap note, template and rubric attached.
template attached
Patient name, GR- will fill in remaining name and vitals at end, other stuff will need to develop
HPI: Patient is a 14 year old male patient who presents with mother for follow-up on depression and ADHD- predominately inattentive type. GR is a 14 year old male who presents with his mother for a follow up visit for the management of depression, social anxiety, and binge eating disorder. He takes Vraylar and Venlafaxine ER 150mg. During last visit, we started Vyvanse 20mg due to
poor focus, inattentiveness, and to assist in the binge eating disorder (BED). He reports feeling some improvement. He feels more energy and is not sleeping all day like he used to. He also relates to decreased appetite and denies episodes of binge eating.Gavin still reports sleeping 12 hours at night. He does not take as many naps as he used to. Patient does online school from home. He relates to improved motivation. Gavin reports moderate depressive and anxiety symptoms. PHQ-9 score is 12. GAD-7 score is 14. His mother reports noticing improved mood. He has been going out more and willing to dine at restaurants. We’ll continue Venlafaxine ER 150mg daily. Increase to Vyvanse 30mg daily in the morning. Follow up in three weeks.
Chief Complaint, patient “I am feeling more motivated and interested in leaving the house.” Mother, states “I see some improvement and he is socializing more with the family at home.”
Medications are: Lisdexamfetamine (Vyvanse) 30 mg capsule, take one tablet every morning, Venlafaxine ER 150 mg capsule ER, take one capsule in the morning, every day
Primary Diagnosis, Depression, moderate, recurrent. ADHD-predominately inattentive type, and Binge Eating disorder (BED). Plus in ICD 10 codes
Differentials: Anxiety, Social anxiety, thyroid abnormality, anemia- iron versus folate/ b12 (micro versus macrocytic anemia)
Follow-up in 3 weeks
Continue current prescriptions x 30 days
Will need at least three references, APA- in past five years- in text citations for differentials and main diagnosis
Psychiatric SOAP Note Rubric
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Criteria |
Ratings |
Points |
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Chief Complaint (Reason for seeking health care) – S |
4 to >3.0 points
Exemplary Includes a direct quote from patient about presenting problem. |
3 to >2.0 points
Distinguished Includes a direct quote from patient and other unrelated information. |
2 to >0.0 points
Developing Includes information but information is NOT a direct quote. |
0 points
Novice
Information is completely missing. |
4 points |
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Demographics – S |
2 points Exemplary Begins with patient initials, age, race, ethnicity, and gender (5 demographics). |
1.5 points Distinguished Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity, and gender). |
1 points Developing Begins with 3 or less patient demographics (patient initials, age, race, ethnicity, and gender). |
2 points |
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History of the Present Illness (HPI) – S |
5 to >3.0 points Exemplary Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
3 to >2.0 points Distinguished Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
2 to >1.0 points Developing Includes the presenting problem and 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
1 to >0 points Novice The presenting problem is not clearly stated and/or there are < 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
5 points |
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Allergies – S |
2 points Exemplary Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy). |
1.5 points Distinguished If allergies are present, student does not list each type of drug, environmental factor, herbal, food, latex name and include severity of allergy OR description of the allergy. |
1 points Developing If allergies are present, student only lists the type of allergy and omits the name of the allergy. |
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Review of Systems (ROS) – S |
5 to >3.0 points Exemplary Includes a minimum of 3 assessments for each body system, assesses at least 9 body systems directed to chief complaint, AND uses the words “admits” and “denies.” |
3 to >2.0 points Distinguished Includes 3 or fewer assessments for each body system, assesses 5-8 body systems directed to chief complaint, AND uses the words “admits” and “denies.” |
2 to >0.0 points Developing Includes 3 or fewer assessments for each body system, and assesses less than 5 body systems directed to chief complaint, OR student does not use the words “admits” and “denies.” |
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Vital Signs – O |
2 points Exemplary Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain). |
1.5 points Distinguished Includes at least 6 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain). |
1 points Developing Includes at least 4 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain). |
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Labs, Diagnostic Tests and Screening Tools – O |
3 points Exemplary During the visit: Includes a list of the labs, diagnostic tests or screening tools reviewed at the visit, values of lab results or screening tools, and highlights abnormal values, OR acknowledges no labs/diagnostic tests were reviewed. |
2 points Distinguished During the visit: Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit, but does not include the values of lab results or screening tools, but does not highlight abnormal values. |
1 points Developing During the visit: Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit but does not include the values of the results or highlight abnormal values. |
3 points |
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Medications-S |
3 points Exemplary Includes a list of all of the patient reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency). |
2 points Distinguished Includes a list of all of the patient reported psychiatric and but omits the medical medications and the diagnosis for the medication (including name, dose, route, frequency). |
1 points Developing Includes a list of some of the patient reported psychiatric and/or medical medications and the diagnosis for the medication (omits the dose, route, frequency of the medications). |
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Past Medical History-S |
3 points Exemplary Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current. |
2 points Distinguished Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current. |
1 points Developing Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current. |
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Past Psychiatric History-S |
4 to >3.0 points Exemplary Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), and year of diagnosis. |
3 to >2.0 points Distinguished Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (omits addiction treatment), and year of diagnosis. |
2 to >0.0 points Developing Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), and does not include the year of diagnosis. |
0 points Novice The information is completely missing. |
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Family Psychiatric History-S |
4 to >3.0 points Exemplary Includes an assessment of at least 6 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts. |
3 to >2.0 points Distinguished Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts. |
2 to >0.0 points Developing Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts. |
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Social History-S |
3 points Exemplary Distinguished Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation. |
2 points Distinguished Includes at least 8 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation. |
1 points Developing Includes all 6 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation. |
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Mental Status Exam-O |
15 to >12.0 points Exemplary Includes all 10 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area. |
12 to >10.0 points Distinguished Includes all 8 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area. |
10 to >0.0 points Developing Includes >6 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with some descriptions for each area. |
0 points Novice Includes <3 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) OR detailed descriptions is not included for each area. |
15 points |
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Primary Diagnoses-A |
11 to >6.0 points Exemplary Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority) using the DSM-5-TR. The correct ICD-10 billing code is used. |
6 to >3.0 points Distinguished Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority using the DSM-5-TR. The correct ICD-10 billing code is used. |
3 to >0.0 points Developing Includes an inaccurate diagnosis as the principal diagnosis. The ICD-10 code is incorrect or missing. |
11 points |
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Differential Diagnoses-A |
3 points Exemplary Includes at least 2 differential diagnoses that can be supported by the subjective and objective data provided using the DSM-5-TR. The correct ICD-10 billing code is used. |
2 points Distinguished Includes 1 differential diagnosis that can be supported by the subjective and objective data provided using the DSM-5-TR. The correct ICD-10 billing code is used. |
1 points Developing Includes at least 1 differential diagnosis that is NOT supported by the subjective and objective data. The ICD-10 code is incorrect or missing. |
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Outcome Labs/Screening Tools – O |
3 points Exemplary After the visit: orders appropriate diagnostic/lab testing or screening tool 100% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time.” |
2 points Distinguished After the visit: orders appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time.” |
1 points Developing After the visit, orders appropriate diagnostic testing less than 50% of the time. |
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Treatment |
10 to >8.0 points Exemplary Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. For non-pharmacological treatment, includes: treatment name, frequency, duration. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is supported by the current US clinical guidelines. |
8 to >6.0 points Distinguished Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4-7 of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. For non-pharmacological treatment, includes: treatment name, frequency, duration. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is supported by the current US clinical guidelines. |
6 to >0.0 points Developing Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4 of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. Non-pharmacological treatment NOT included. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is NOT supported by the current US clinical guidelines OR is unsafe. |
10 points |
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Patient/Family Education-P |
5 to >3.0 points Exemplary Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives. |
3 to >2.0 points Distinguished Includes at least 2 strategies to promote and develop skills for managing their illness and at least 2 self-management methods on how to incorporate healthy behaviors into their lives. |
2 to >0.0 points Developing Includes at least 1 strategies to promote and develop skills for managing their illness and at least 1 self-management methods on how to incorporate healthy behaviors into their lives. |
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Referral |
3 points Exemplary Provides a detailed list of medical and other interdisciplinary referrals or documents NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments. |
2 points Distinguished Provides a medical or other interdisciplinary referral or documents NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments. |
1 points Developing Provides a medical or other interdisciplinary referral. DOES NOT include a timeline for follow up appointments. |
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APA Formatting |
5 to >3.0 points Exemplary Effectively uses literature and other resources to inform their work. Exceptional use of citations and extended referencing. High level of precision with APA 7th Edition writing style. |
3 to >2.0 points Distinguished Effectively uses literature and other resources to inform their work. Moderate use of citations and extended referencing. Moderate level of precision with APA 7th Edition writing style. |
2 to >0.0 points Developing Ineffectively uses literature and other resources to inform their work. Moderate use of citations and extended referencing. APA 7th Edition writing style not strictly adhered to. |
0 points Novice APA style and writing mechanics not used. |
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References |
5 to >3 points Exemplary The reference page contains at least the required current scholarly academic reference and text reference. Follows APA guidelines of components: double space, 12 pt. font, abstract, level headings, hanging indent and in-text citations. |
3 to >2 points Distinguished References page contains one current scholarly academic resource and text reference. Follows most APA guidelines of components: double space, 12 pt. font, abstract, level headings, hanging indent, and in-text citations. |
2 to >0 points Developing References page contains one current or outdated scholarly academic resource. Many errors of APA guidelines: double space, 12 pt. font, abstract, level headings, hanging indent, and in-text citations. |
0 points Novice References page contains no current scholarly academic resources, only internet webpages or no reference page. Lack of APA guidelines for references provided or in-text citations. |
MENTAL STATUS EXAM GUIDE
Previous Mental Health Treatments (e g: psychopharmacology, inpatient stabilization, Occupational Therapy, Vocational Therapy, Marriage/Family Therapy, Group Therapy, Detox, ECT &/or social services):
What is the initial impression of the admitting examiner found in the initial evaluation, triage, or social worker note:
Compare your impression of the patient’s status now to the initial impression:
BRIEF MENTAL STATUS EXAM
Instructions; Most information can be obtained during an interaction with the patient without asking specific questions. The information must be described to support your conclusion.
GENERAL DESCRIPTION
Appearance (e.g. grooming, manner of dress, level of hygiene, facial expression, remarkable features, height, weight, nutritional status, presence of piercings, tattoos, scars, the relationship between appearance and age, etc.):
Attitude toward examiner
(INCLUDED IN BEHAVIOR) – Does the patient have good eye contact? Are they cooperative, friendly, attentive, interested, frank, seductive, defensive, playful, apathetic, evasive, guarded, etc.:
Speech characteristic –
What are the qualities of the patient’s speech include tone, inflection, volume, pronunciation (clear or slurred; mumbling; defects, lisp, stuttering), speed:
What is the quantity of the patient’s speech? Does the patient verbalizes freely, provide monosyllabic answers, have pressured speech, and/or are they hyperverbal:
Psychomotor activity
(INCLUDED IN BEHAVIOR)
Is the patient experiencing hypoactive psychomotor activity that can include generalized slowing down of body movements, aimless, purposeless activity, etc.? Write your description and conclusion:
Is the patient experiencing hyperactive psychomotor activity that can include restlessness, agitation, combativeness, wringing of hands, pacing, etc.? Write your description and conclusion:
MOOD/AFFECT
Mood – is the sustained/consistent emotion that colors their perception of the word.
Is the patient’s mood sad, labile, euphoric, euthymic, expansive, anhedonic, etc.
Is the patient anxious, angry and/or depressed? Assess for mild, moderate, or severe and document findings that support your conclusion.
IMPORTANT: Ask the patient if they are having any suicidal or homicidal thoughts, if the patient indicates in any way that they, then ask them if they have a plan and report these findings to the staff immediately so measures can be taken to safeguard the patient.
Affect – Patient’s current emotional reaction that is being inferred from the patient’s facial expression.
What is the range of the patient’ affect (full or restricted)? What findings support your conclusion:
Is the patient’s affect appropriate; is the emotional expression congruent with the thought content? What findings support your conclusion:
Is the intensity of the patient’s affect blunted or flat, shallow, labile, proud, angry, fearful, anxious, guilty, etc.? What findings support your conclusion:
Does the patient have difficulty in initiating, sustaining, or terminating an emotional response? What findings support your conclusion:
DISORDERS OF THE FORM OF THOUGHT
The thought process refers to the way a person puts together ideas and associations. Is the patient disorganized, coherent, has a flight of ideas, though blocking, tangential, circumstantial, rambling, evasive? Is there a lack of cause and effect relationship and goal-directed thinking:
Thought content refers to what the person is thinking and speaking about. Does the patient have preoccupations: about illness, environmental problems, obsessions, compulsions, phobias; obsessions about suicide, homicide, hypochondriacal symptoms, and specific antisocial urges:
IMPORTANT: Ask the patient if they are having any suicidal or homicidal thoughts, if the patient indicates in any way that they, then ask them if they have a plan and report these findings to the staff immediately so measures can be taken to safeguard the patient.
Does the patient’s thought content contain delusional material? If yes, describe the types of delusion(s)? Include in your description details about the extent and nature of the delusions:
PERCEPTION
(INCLUDED IN THOUGHT CONTENT)
Hallucinations are a form of disturbance of the sensory system. To determine if someone is experiencing them you can the person “Have you ever heard voices or sounds that no one else can”? “Smelled something that no one else can?” “Felt like bugs were crawling all over you?” “Seen something that no one else can see?” Include in your description details about the extent and nature of the hallucination and how you reached this conclusion:
Illusions are a misperception of a person-environment such as an exit sign that looks like the devil.
COGNITION
Orientation
Person:
Place:
Time:
Is the patient’s orientation good, fair or poor; support your conclusion:
Memory functions are usually divided into remote memory, recent past memory, recent memory and immediate retention and recall.
Remote – Can the patient provide childhood data; important events: time and place of birth; various schools attended; number of children and ages and names. Is the patient’s remote memory good, fair or poor; support your conclusion:
Recent Past Memory – Can the patient tell you what they did yesterday, what did they have for breakfast, lunch, dinner? Is the patient’s recent past memory good, fair or poor; support your conclusion:
Tell the patient that you are going to ask them to repeat the three words you are going to tell them, pen, apple, watch. After the patient is finished, remind him/her that you will be asking them these in a few minutes,
Recall /Immediate Retention Memory – Ask the patient to repeat the three word you have just finished saying. Is the patient’s recent memory good, fair or poor; support your conclusion:
Recent Memory – Ask the patient to repeat the three words you told them a few minutes ago. Is the patient’s recent memory good, fair or poor; support your conclusion:
Concentration and attention is the ability to remain focused. Is the patient’s attention span good, slight, moderate or severely distractible?
Abstract/Concrete thinking is the ability to deal with concepts. Proverbs or “similarities” can determine if the patient is an abstract or concrete thinker. Ask “What do people generally mean when they say… Don’t count your chickens before they’re hatched?”. When using similarities, ask, “In what ways are an apple and a banana alike?” Is the patient’s ability to abstract good, fair or poor; support your conclusion:
JUDGMENT AND INSIGHT
Judgment is the patient’s understanding of socially conforming behavior and the ability to understand the outcome of their behavior. If you are not aware of the patient’s judgment as what is the thing to do if you are the first person in the theatre to discover a fire and/or what will you do when you are discharged from the hospital. Is the patient’s judgment good, fair, poor; support your conclusion.
Insight is the patient’s awareness of the illness and the understanding of the outcome. Is the patient’s insight good, fair, poor; support your conclusion:
BIOLOGICAL DATA
Oxygenation:
Respiration: (Quality and quantity):
Temp:
B/P:
Pulse: (Quality and quantity):
Metabolism
Ingestion includes the patient’s nutritional intake. How many times does he/she eat full meals or snacks per day? What do the meal and snack consist of, is the patient on a specific diet, and is the patient’s report congruent with the diet limitations:
Digestion includes gas/burping, reflux, acid indigestion, nausea/vomiting, pain, ulcer, bloating, etc. Does the patient have any digestion difficulties?
Elimination includes gas/flatulence, diarrhea, loose stools, constipation, etc. How many BMs/day? Is the consistency normal? Is there any blood in the stool:
Sleep Patterns
Quality – Does the patient have difficulty falling asleep or falling back to sleep? Are they tired upon awakening? Do they have early morning awakening, bad dreams, and nightmares? Do they wet the bed, walking in sleep, etc.:
Quantity – How many hours of sleep does the patient need to feel good in the morning? How many hours of sleep do they get now? What time do you go to sleep & wake up:
SOCIAL HISTORY
Support system: (Is there support from family, friends, church, work, etc.):
Occupation – (Any job in the past or present, employee or volunteer; would the patient like to have a job, what would that job be):
Spiritual Assessment
What importance does religion/spirituality have in the patient’s life:
Do the patient’s beliefs help with stressful situations:
Education – What was the highest level of school completed; any vocational training programs attended; would the patient like to go back to school or vocational training:
Financial Support – who works in the household; what other means of financial support is there for the household:
Interests – What does the patient do in their spare time (e.g. watch TV; exercise; fishing; woodcraft; reading; theatre; movies; bowling; walking; running; crossword puzzles etc.):
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Psychiatric SOAP Note Template
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
SI/HI: _______________________________________________________________________________
Sleep: _________________________________________
Appetite: ________________________
Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________
Current perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
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Date |
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Hospital |
Diagnoses |
Length of Stay |
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Outpatient psychiatric treatment:
|
Date |
Detox/Inpatient substance treatment:
Date
Hospital
Diagnoses
Length of Stay
History of suicide attempts and/or self injurious behaviors:
____________________________________
Past Medical History
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
Past Surgical History___________________________________________________________
Current psychotropic medications:
_________________________________________ ________________________________
_________________________________________ ________________________________
_________________________________________ ________________________________
Current prescription medications:
_________________________________________ ________________________________
_________________________________________ ________________________________
_________________________________________ ________________________________
OTC/Nutritionals/Herbal/Complementary therapy:
_________________________________________ ________________________________
_________________________________________ ________________________________
Substance use
: (alcohol, marijuana, cocaine, caffeine, cigarettes)
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Substance |
Amount |
Frequency |
Length of Use |
Family Psychiatric History: _____________________________________________________
Social History
Lives: Single family House/Condo/ with stairs: ___________
Marital Status:________
Education:____________________________
Employment Status: ______
Current/Previous occupation type: _________________
Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________
Sexual Orientation: _______ Sexual Activity: ____
Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone
: _____________________________
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________
________________________________________________________________________
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____
Exposures:
Immunization HX:
Review of Systems:
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
Physical Exam
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
percentile) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
Mental Status Exam
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
Significant Data/Contributing Dx/Labs/Misc.
Plan:
Differential Diagnoses
1.
2.
Principal Diagnoses
1.
2.
Plan
Diagnosis #1
Diagnostic Testing/Screening:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Diagnosis #2
Diagnostic Testingg/Screenin:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
DEA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)______________________________ Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________
Refill: _________________
No Substitution
Signature: ____________________________________________________________
Rev. 10162021 LM
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