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Template Outpatient Psych Note Counseling and Coord Start

The psychiatric progress note summarizes a patient visit. It documents the patient's interval history and mental status examination. The note states the current diagnoses and any diagnosis updates or medication changes. It also indicates if any lab tests were ordered or reviewed. Counseling was provided to the patient and/or family on diagnostic results, treatment options and risks/benefits, management/treatment instructions, compliance, education and prognosis. Coordination of care occurred with nursing, residential staff, social work, physicians and family. The duration of the face-to-face visit with the patient is documented.

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trowell33
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491 views1 page

Template Outpatient Psych Note Counseling and Coord Start

The psychiatric progress note summarizes a patient visit. It documents the patient's interval history and mental status examination. The note states the current diagnoses and any diagnosis updates or medication changes. It also indicates if any lab tests were ordered or reviewed. Counseling was provided to the patient and/or family on diagnostic results, treatment options and risks/benefits, management/treatment instructions, compliance, education and prognosis. Coordination of care occurred with nursing, residential staff, social work, physicians and family. The duration of the face-to-face visit with the patient is documented.

Uploaded by

trowell33
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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OUTPATIENT/OFFICE PSYCHIATRIC PROGRESS NOTE

COUNSELING AND/OR COORDINATION OF CARE


Patients Name: _________________________________________________________Date of Visit:______________________
Interval History:__________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________

Interval Psychiatric Assessment/ Mental Status Examination:


___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________

Current Diagnosis:________________________________________________________________________________________
Diagnosis Update:_________________________________________________________________________________________
Current Medication(s)/Medication Change(s) No side effects or adverse reactions noted or reported

_______________________________________________________________________________________________
________________________________________________________________________________________________________
Lab Tests: Ordered

Reviewed : _____________________________________________________________________

________________________________________________________________________________________________________
Counseling Provided with Patient / Family / Caregiver (circle as appropriate and check off each counseling topic discussed
and describe below:
Diagnostic results/impressions and/or recommended studies

Risks and benefits of treatment options

Instruction for management/treatment and/or follow-up


options

Importance of compliance with chosen treatment

Risk Factor Reduction

Patient/Family/Caregiver Education

Prognosis

_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Coordination of care provided (with patient present) with (check off as appropriate and describe below):
Coordination with: Nursing Residential Staff Social Work Physician/s Family Caregiver
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Additional Documentation (if
needed):________________________________________________________________________
________________________________________________________________________________________________________
_
________________________________________________________________________________________________________
_
Duration of face to face visit w/patient :

min. Start Time ___________ Stop Time __________CPT____________

Greater than 50% of face to face time spent providing counseling and/or coordination of care:

Seth P. Stein 2007

Psychiatrists Signature:_____________________________________Date:_____________

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