DIAGNOSTIC EVALUATION
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1 DIAGNOSTIC EVALUATION NAME: DOB: Age: Referred by: Date: HISTORY: A. CC & HPI ("S&S", onset, severity, duration) B. Past Hx (Psych; Med ill, operations) C. GENOGRAM PSYCHIATRIC EXAM Constitutional: 3 VS (sitting, standing, supine BPs; T;P;R; HT; WT) General appearance (dev., nutrition, grooming) Speech (rate; vol.; fluidity; coherence; spontaneity; perseveration, paucity) Musculoskeletal: Muscle strength & tone (normal; flaccid; cog wheel rigidity; spasticity; atrophy; abnormal movements: tremor, dyskinesia) Gait & station (Ataxic: unsteady, wide-based; staggering; Parkinsonian: stooped, hip/knee flexion; short/shuffling steps; arm swing) Thought processes (content [logical, illogical, tangential]; abstract reasoning; computation) Associations (LOA, FOI, circumstantial, blocking, vague, intact) Judgment and insight (re. everyday act. & social situations; psych. condition) good, fair, poor Recent and remote memory Language (naming objects, repeating phrases) Mood & affect (depression, anxiety, agitation, hypomania, lability) Abnormal/Psychotic thoughts (hallucination, delusions; HI, SI, obsessions) Orientation to person, place, time Attention span & concentration Fund of knowledge (aware of current events, past history, vocabulary) DIAGNOSIS: Axis I Axis II Axis III Axis IV Axis V SUMMARY/PLAN: Signature Time Code
2 PAGE 2 NAME: Additional information: Target Symptoms Goals: Acute: improve health or function Chronic: stabilize or maintain health or function Psychiatric Therapeutic Procedures: Insight Oriented/Behav. Mod/Supportive Psychotherapy Interactive Psychotherapy Psychotherapy with Medical E & M Consultation Family Therapy Pharmacologic Management Other Rationale for type of therapy: Dev. of insight or affective understanding Alleviate emotional distress Change maladaptive patterns of behavior Encourage personality growth Eval. comorbid med. conditions Med. management, drug interactions, SE Collaborate with healthcare providers Resources: Family Social Professional Community Spiritual Other Bibliotherapy Patient has capacity to participate & benefit in: Psychotherapy Meds Combination Other Estimated duration of treatment (# sessions): Methods used to monitor outcome: Report of: patient family staff physician/np/pa observation questionnaires (name) Optional: ROS ( pos. or neg. respon: Prob pert = 1-2; Ext = 2-9; Complete = 10) EYES ENMT CV RESPIRATORY GI GU MS SKIN NEURO ENDO HEM/LYMPH/IMMUN OTHER Signature:
3 EVALUATION & MANAGEMENT SERVICES PATIENT: Date: HISTORY: CC "S&S", problem/dx, rec. return; HPI onset, severity; Brief = 1-3; Ext = 4 elements; PFSH (unchanged, recorded) Pertinent = 1; Complete = 2-3 ROS (pos. or neg. respon: Pert. prob = 1; Ext = 2-9; Complete = 10) EXAM (PF = 1-5 elements; EPF = 6 elements; Detailed = 9 elements; Comp = Psych +/or >/= 10 elements): EYES ENMT CV RESPIRATORY GI GU MS SKIN NEURO ENDO HEM/LYMPH/IMMUN OTHER PSYCHIATRIC EXAM (PF = 1-5; EPF = 6; DETAILED = 9) Constitutional: 3 VS (sitting, standing, supine BPs; T;P;R; HT; WT) Musculoskeletal: Muscle strength & tone (normal; flaccid; cog wheel rigidity; spasticity; atrophy; abnormal movements: tremor, dyskinesia) General appearance (dev., nutrition, grooming) Speech (rate; vol.; fluidity; coherence; spontaneity; perseveration, paucity) Gait & station (Ataxic: unsteady, wide-based; staggering; Parkinsonian: stooped, hip/knee flexion; short/ shuffling steps; arm swing) Thought processes (content [logical, illogical, tangential]; abstract reasoning; computation) Associations (LOA, FOI, circumstantial, blocking, vague, intact) Judgment and insight (re. everyday act. & social situations; psych. condition) good, fair, poor Recent and remote memory Language (naming objects, repeating phrases) Mood & affect (depression, anxiety, agitation, hypomania, lability) Abnormal/Psychotic thoughts (hallucination, delusions; HI, SI, obsessions) Orientation to person, place, time Attention span & concentration Fund of knowledge (aware of current events, past history, vocabulary) DIAGNOSIS: Axis I Axis II Axis III Axis IV Axis V COUNSELING/COORDINATION, SUMMARY, PLAN: Med Dec: #Dx (minimal, ltd, multi, ext); Data: (record, fam: minimal, ltd, mod, ext); Risk (comorbids/exacerbation: minimal, low, mod, high);=straightforward,; Low, Mod, High Complexity DX: improv, controlled, resolved, worse, inadeq control, failing to change as expected; Manag: pt tch, nsg tch, therapies, meds; consults referrals, advice; symptoms without Dx: Differentials, possible, probable, R/O
4 PSYCHOTHERAPY NOTES Patient: Date: Session # Summary: Mental Status Exam: ٱ No Significant change Orientation Appearance Speech/Motor Mood/Affect Thought process Thought content Cognition SI/HI Insight oriented, behavior mod, or supportive psychotherapy was used to: Meds Impression/Response to Treatment: Improving Controlled Resolved Inadequate control Plan: Date: Session # Summary: Mental Status Exam: ٱ No Significant change Orientation Appearance Speech/Motor Mood/Affect Thought process Thought content Cognition SI/HI Insight oriented, behavior mod, or supportive psychotherapy was used to: Meds Impression/Response to Treatment: Improving Controlled Resolved Inadequate control Plan: MEDICATION MANAGEMENT FORM PATIENT: ALLERGIES: NKDA NKFA NONPSYCHOTROPIC MEDICATIONS
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1 2 3 4 5 Elements: Location, Timing, Associated Sign and Symptom, Duration Type of History HPI Problem Focused (99201, 99213) Brief (1-3) Expanded Focused (99202, 99213 Brief (1-3) Detailed (99203, 99214)
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