Include all of the following in each write-up.
Demographics: Age, gender, race/ethnicity, educational level.
Setting: Place where patient encounter took place.
Reason for and Type of Visit: Intake, follow-up; psychotherapy or medication management.
Diagnosis: Current diagnosis/diagnoses and the DSM-5 criteria that matches the symptoms or history of symptoms.
Rating Scales: Any diagnostic rating scales that would be appropriate for this patient.
History of Present Illness: What has recently happened and what is currently going on with patient? Use the eight HPI elements per CPT coding (timing, severity, and so on).
Psychiatric History: When patient first started treatment, previous medications, previous inpatient/outpatient treatment, previous diagnoses and age when diagnosed, previous self-harm, and suicidal/homicidal ideations.
Substance Abuse History: Any current or past history of substance use (drugs/alcohol/marijuana/nicotine); if patient has a history of substance use, include how long the patient has been sober.
Family Psychiatric History: Any family psychiatric history.
Medical/Surgical History: Any medical problems or previous surgeries.
Medications: For each medication, include name of the medication (both brand name and generic), medication class, patient’s current dose, how the medication works (include the CYP450 system if applicable), patient education for this medication, drug/drug interactions, and lab tests that would need to be ordered for monitoring; include all medications.
Mental Status Exam: Please include a mental status exam.
Points Discussed in Visit: What did you and your preceptor discuss in the visit? Please list any major talking points between you and your preceptor.
Therapy Recommendations: List any current therapy the patient is undergoing. Also, please state what type of therapy would work best for this patient with the given diagnosis. Include a reference supporting your therapy recommendation.
Clinical Impression: How you thought the visit went, how receptive to the recommendations the patient appeared, and any mannerisms of the patient that you observed.
Diagnosis Code: The ICD 10 diagnosis code(s) for this visit; include all appropriate specifiers. Include the billing/CPT code for the visit.
Treatment Recommendations: Follow-up recommendations: time before next visit, therapy recommendations, and so on.
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