Visit Information

• Setting and Location: In-person or by telehealth.
• Date of Service: MM/DD/YYYY
• Informants and Records Reviewed: Collateral information, and any records reviewed.
• Consent and Confidentiality: Informed consent, telehealth consent and any release of information, only if discussed.
• Age and Gender: In years, Gender stated

Reason for Consultation

• Chief Complaint: Why the patient came in, whether they are a new or established patient, and their symptoms and goals in their own words.
• History of Presenting Illness: Symptoms, frequency, severity, onset, and any changes from previous session(s) when applicable
• Past Psychiatric History: Past diagnoses, symptoms and treatments related to the current presenting problems.
• Functional Assessment: Functioning at work, school, home, in relationships and in self-care, and any changes since the last visit.

Symptom Checklist/Review of Systems

If a category has no symptoms, it says “None reported.”

• Psychiatric: Mood, anxiety, trauma and perceptual symptoms reported.
• Constitutional & Somatic: Energy, sleep, weight, appetite and physical symptoms reported.
• Neurological: Tremor, involuntary movements, headaches, dizziness or cognitive changes reported.
• Endocrine & Metabolic: Heat or cold intolerance, thirst or frequent urination reported.

Risk

Current risk items highlighted in red.

• Suicidal Ideation: Ideation, intent, plan, means, preparatory behavior, deterrents and reasons for living.
• Self-Harm: Urges and behavior.
• Homicidal Ideation or Harm to Others: Ideation, intent, plan and any identified target.
• Violence and Aggression: Urges, threats and behavior.
• Access to Means: Firearms, stockpiled medications or other means, and any restriction agreed.
• Warning Signs: Signs that the patient is getting worse.
• Protective Factors: Supports, reasons for living and engagement in treatment.
• Risk Management: Safety planning, crisis resources discussed (including 988 and 911) and actions taken to reduce risk.

Mental Status Examination

• Appearance: Grooming, dress and physical presentation as observed
• Behavior: Activity level, cooperation, eye contact and any notable behaviors as observed
• Speech: Rate, rhythm, volume and tone as observed
• Mood: Patient’s reported mood, using their own words where possible
• Affect: Range, congruence and appropriateness as observed, noting any discrepancy with the stated mood
• Thought Process: Organization, coherence and goal-direction
• Thought Content: Preoccupations, delusions and intrusive thoughts, recording unwanted thoughts the patient finds distressing and rejects in the patient’s own terms
• Perception: Reported hallucinations or sensory misinterpretations, with type and impact
• Cognition: Memory, orientation, concentration and comprehension
• Insight: Patient’s understanding of their own condition and treatment
• Judgment: Patient’s decision-making ability and understanding of consequences

Medication Review

• Current Medications: Name, dose, route, frequency and prescriber for each medication.
• Changes This Session: Any medication started, increased, decreased, held, stopped or refilled, and why.
• Side Effects: What was reported, how severe it was and how it was managed.
• Adherence: How the patient takes the medication, missed doses and barriers.
• Allergies: Drug allergies, or no known drug allergies.

Past Medical History

• Prior Medical History: Past diagnoses, illnesses, surgeries and hospitalizations.
• Prior Medication: Past medication trials, doses, benefits and why they were stopped.

Sleep:

Falling asleep, staying asleep, early waking, total hours, quality and how medication affects sleep.

Appetite and Nutrition:

Appetite changes, weight changes, eating patterns and nutrition advice given.

Substance Use:

Only the substances raised from the following: alcohol, tobacco and nicotine, cannabis, stimulants, opioids, sedatives, hallucinogens, caffeine and other. Includes current use, changes, cravings, withdrawal and interactions with prescribed medication.

Clinical Assessments Administered:

Any administered measure’s name, score, severity band, date and change from the last score.

Assessment:

Summary of symptoms, functioning, medication efficacy, tolerance, and additional current stressors and supports.

Diagnoses:

Diagnoses the clinician named, with DSM-5-TR and ICD-10-CM codes, plus any rule-outs or differentials.

Medical Necessity:

Why prescriber-level evaluation and management was needed, and what continued treatment aims to achieve.

Interventions, Psychoeducation and Supportive Therapy:

What the clinician explained, taught or reinforced, and how the patient responded.

Treatment Plan:

Included only if the source contains one.

Prescription Drug Monitoring Program:

Whether the PDMP was checked

Plan:

A numbered list of medication actions, labs and monitoring, referrals, psychotherapy, lifestyle advice, safety steps and any options the patient declined.

Risks and Benefits of Medication Counseling:

Counseling on the risks, benefits, side effects and importance of taking medication consistently.

Follow-Up:

When the next visit is, and when the patient should get in touch sooner.