This is where the “facts” are located.
**Physical Exam (if performed, will not be performed every visit in every setting)
Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.
DSM5 Diagnosis: with ICD-10 codes
Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent.
Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.
Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.
Informed Consent Ability
Psychiatric. Admits to X as per HPI.
Estimated stay 3-5 days
Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time.
Patient denies abnormal perceptions and does not appear to be responding to internal stimuli.
Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic:
· No changes to current medication, as listed in chart, at this time
· or…Zoloft is an excellent option for many women who experience any menstrual cycle complaints. I usually start at 50 mg and move to 100 week 6-8. f/u within 2 weeks initially then every 6-8 weeks.
· Psychotherapy referral for CBT
Education, including health promotion, maintenance, and psychosocial needs
· Importance of medication
· Discussed current tobacco use. NRT not indicated.
· Safety planning
· Discuss worsening sx and when to contact office or report to ED
Referrals: endocrinologist for diabetes
Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks
☒ > 50% time spent counseling/coordination of care.
Time spent in Psychotherapy 18 minutes
Visit lasted 55 minutes
Billing Codes for visit:
Date: Click here to enter a date. Time: X
Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment and include patient education.