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    Last Modified 1/6/2009

    General Psychiatry Evaluation Medical Note Template

    The general psychiatry evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected psychiatric disorders such as depression and bipolar disorder.  This MedicalTemplate includes all the required elements for the high complexity E&M documentation, tailored for the needs of mental health professionals.

    How to use MedicalTemplates

      Read this document on Scribd: Psychiatry Evaluation

      Psychiatry Evaluation Prototype Date Start time Stop time Patient Name Chief complaint/Reason for consult Patient DOB Referring MD MRN Substance Use History ‰Never Smoker ‰Tobacco ____ # Packs X ____ # Yrs ‰ Quit ‰Patient is unwilling to quit ‰Patient willing to consider quitting ‰Patient quit, but resumed smoking ‰Patient willing to quit within 1 month Patient has tried History of Present Illness ‰Patient is Nonverbal. History obtained from ‰ Family ‰ Medical records ‰Nicotine replacement ‰Buproprion or nortriptyline ‰Nicotine receptor blockade Drinks per ‰day ‰week Hazardous drinking NIAAA (National Institute on Alcoholism and Alcohol Abuse guidelines) ‰Alcohol use Daily, occasional and ex-smokers are more likely to be hazardous drinkers Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day ‰Depressed mood most of the day ‰Diminished interest in friends, family, usual activities ‰Significant weight loss or gain ‰Insomnia or hypersomnia ‰Psychomotor retardation or agitation ‰Fatigue ‰Feelings of worthlessness or excessive guilt ‰Decreased concentration ‰Loss of ability to carry out daily functions ‰Suicidal ideation ‰No plan ‰With plan ‰Homicidal ideation ‰No plan ‰With plan Past Psychiatric History ‰Anxiety ‰Bipolar disorder ‰Mania ‰Psychosis ‰Hospitalizations for psychiatric illnesses Last hospitalization Review of Systems ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰Inflated self esteem, or grandiosity ‰Pressured speech ‰Flight of ideas ‰More easily distractible ‰Increase in goal-directed activity ‰Excessive involvement in pleasurable activities ‰Increased restlessness, or feeling keyed up ‰Hallucinations ‰New or increased substance abuse ‰Patient has the means to carry out Suicidal Plan ‰Patient has the means to carry out Homicidal Plan ‰Depression ‰Schizophrenia ‰History of ECT Last treatment ‰Prior Suicide attempts Last attempt ‰Recreational drug use ‰Inhalational ‰Injectable ‰Ingestible ‰Drug dependence ‰Narcotics ‰Benzodiazepines Allergies ‰ Allergy List reviewed ‰ No drug allergies ‰ No food allergies Medications ‰Medications reviewed ‰Medications reconciled with Nursing Home or Hospital discharge Information œ46 Changes as follows Constitutional ‰Fatigue ‰malaise ‰fever/chills ‰change in appetite Eyes ‰Vision changes ‰New pain ‰Scotomas ENT/mouth ‰Nose bleeds ‰dental caries ‰dental abscesses ‰jaw pain Resp ‰Dyspnea ‰Cough ‰Phlegm ‰Hemoptysis ‰Wheeze CV ‰Chest pain ‰diaphoresis ‰Ankle edema ‰PND ‰syncope GI ‰Nausea ‰Weight changes ‰Constipation ‰Diarrhea ‰Abdominal pain GU ‰Change in urinary habits ‰Hematuria ‰Dysuria Musc ‰Myalgias ‰Recent trauma ‰Bony fractures ‰Arthralgias ‰Joint swelling Skin/breasts ‰Rashes ‰Masses or skin lesions ‰Increased sensitivity to sun Neuro ‰Seizures ‰Episodic or chronic muscle weakness ‰Headaches Endo ‰Hair loss ‰Polydipsia Heme/lymph ‰Bleeding gums ‰Unusual bruising ‰swollen lymph nodes Allergy/Immun ‰Sinus probs ‰Recurrent infections Psych See HPI Surgical History ‰ Malignancy ‰ Neuromuscular weakness ‰ Obstructive Sleep Apnea ‰ Renal Dysfunction ‰ Seizure Disorder ‰ Thrombotic Disease ‰ Thyroid Disease ‰ Tuberculosis Family Medical History ‰Asthma ‰Seizure Disorder ‰CHF ‰Substance abuse ‰COPD ‰Thrombotic Disorder ‰CAD ‰Thyroid disease ‰Malignancy ‰Thalassemia ‰Anxiety Disorder ‰Bipolar Disorder ‰Major Depressive Disorder ‰Schizophrenia Past Medical ‰ Asthma ‰ Cerebral Artery Disease ‰ Congestive Heart Failure ‰ COPD ‰ Coronary Artery Disease ‰ Diabetes ‰ Hepatic Dysfunction ‰ HIV or AIDS ‰ Hypertension İMB and RR 2006-2008 Revised 20Feb08 e-medtools.com Psychiatry Evaluation Prototype Patient Assets Patient Name Social History Family of origin Current Family/Support Nutrition Exercise Abuse History School Work Hobbies Spiritual History Patient DOB MRN Physical Exam and Mental Status General Eye ENT Neck Resp CV GI Lymph Musc Skin Neuro Psych ✔ ‰Checked box indicates findings are within normal limits ‰ Alert Vitals Ht Wt T P ‰Regular ‰Irregular R ‰ Conjunctivae ‰Pupils ‰Discs ‰Pharynx ‰Dentition ‰ Nasal ‰External ears ‰ Hearing ‰ Exam ‰ Thyroid ‰ Clear to auscultation ‰ Clear to percussion ‰Effort ‰Normal to palpation ‰ Auscultation ‰ Palpation ‰ Edema ‰Carotids ‰ Aorta ‰Femoral pulses ‰ Pedal pulses ‰Abdomen ‰No hepatosplenomegaly ‰No hernias ‰Rectum ‰ Guaiac ‰Neck ‰Axilla ‰Groin ‰Other ‰Gait ‰Strength ‰Tone ‰ Inspection ‰ Palpation ‰DTR ‰Sensation ‰Coordination Cranial Nerves ‰II ‰III+ ‰V ‰VII ‰VIII ‰IX ‰XI ‰XII ‰Associations ‰Delusions Mental Status BP mmHg ‰Speech ‰Orientation ‰Memory ‰Concentration ‰Affect ‰Language ‰Knowledge ‰Thought ‰Insight Impression Axis I Treatment Plan Axis II Axis III Axis IV Axis V Signature cc Data Reviewed: ‰ER Notes ‰Chart ‰Nursing Notes ‰ECG İMB and RR 2006-2008 Care Coordinated with: ‰HCPOA ‰ PCP ‰Case Mgmt or SW ‰Pharmacy ‰Nursing Revised 20Feb08 e-medtools.com


      Template updated 3/4/2008

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    E & M Documentation Template

    The general psychiatry evaluation MedicalTemplate contains prompters and space for all the required elements for a E&M encounter.  

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    Digital Health Record

    The general psychiatry evaluation MedicalTemplate functions like all other PDF files, but they have editable text fields and working checkboxes.  This allows information to be typed in or pasted from other applications to fill out the template.

    Filled general psychiatry evaluation MedicalTemplates can be printed and saved to a computer, USB drive, CD, DVD, or other storage device to create a digital health record for your patients.

    To learn more about how MedicalTemplates can be used as a digital health record, click here.

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    Digital Signature Enabled

    General psychiatry evaluation MedicalTemplates can be signed with a digital signature, instead of a handwritten signature, if the use of a digital signature is acceptable at your practice location.   Adobe PDF digital signatures require the creation of a digital ID that is used to sign the PDF.  

    To learn more about Adobe PDF digital signatures, click here.

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    MedicalTemplates are in the Adobe PDF format, which requires the free Adobe Reader.  With Adobe Reader, these templates can be printed as many times as needed on paper meeting your specifications or the specifications of any clinic, hospital, or other health care facility.