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Generic Normal Psychiatric Established-Patient Med Check

This document is a progress note for a patient's medication management appointment on March 17, 2016. It includes the patient's history, current medications, and review of symptoms. The provider notes the duration of effectiveness for the patient's stimulant medication and their sleep patterns. The impression and plan section lists the patient's diagnoses and plan for follow up in 1-4 weeks or 2-3 months. The review of systems and mental status examination are also documented as normal or negative.

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231 views2 pages

Generic Normal Psychiatric Established-Patient Med Check

This document is a progress note for a patient's medication management appointment on March 17, 2016. It includes the patient's history, current medications, and review of symptoms. The provider notes the duration of effectiveness for the patient's stimulant medication and their sleep patterns. The impression and plan section lists the patient's diagnoses and plan for follow up in 1-4 weeks or 2-3 months. The review of systems and mental status examination are also documented as normal or negative.

Uploaded by

keisha
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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PRACTICE NAME

Progress Note or Medication Review


3
Patient Name: ___________________DOB _______________
MARCH 17, 2016

MRN_____________Date: THURSDAY,

HISTORY
CHIEF COMPLAINT/REASON FOR ENCOUNTER:
In for medication management
HPI

(1-3 elements - Brief; 4+ elements Extended )

Elements: Location, Quality, Severity, Duration, Timing, Content, Modifying Factors, Associated
Signs & Symptoms
PAST, FAMILY, SOCIAL HISTORY (PFSH) ___ Check if no change (1 history area Pertinent; 2-3 history areas
Complete)

*****See attached ROS and PE


CURRENT MEDICATIONS:
MEDICATION CHANGES:
AE Y/N______________________________ ________________________________
AE Y/N______________________________ ________________________________
AE Y/N______________________________ ________________________________
AE Y/N______________________________ ________________________________
AE Y/N______________________________ ________________________________
AE Y/N______________________________ ________________________________
AE Y/N______________________________ ________________________________
AE Y/N______________________________ ________________________________
AE Y/N______________________________ ________________________________
AE Y/N______________________________ ________________________________
AE Y/N______________________________ ________________________________
Increase Decrease C/Continue /C Discontinue A/Add TM/Too Much TL/Too Little
NOTES:

Provider Signature

March 17, 2016

PRACTICE NAME
Progress Note or Medication Review
3
Duration of Effectiveness of Stimulant __________

Avg. Hours of Sleep_____ Difficulty Falling__ / Remaining__ Asleep

IMPRESSION/PLAN:
DIAGNOSIS Status: ___Improving ___Worsening___Unchanged

___Stable ___Unstable

DIAGNOSIS Status: ___Improving ___Worsening___Unchanged

___Stable ___Unstable

DIAGNOSIS Status: ___Improving ___Worsening___Unchanged

___Stable ___Unstable

DIAGNOSIS Status: ___Improving ___Worsening___Unchanged

___Stable ___Unstable

DIAGNOSIS Status: ___Improving ___Worsening___Unchanged


F/U __1 WK

__2 WK

__3 WK

___Stable ___Unstable

__4 WK __2 MTH __3 MTH

General ROS
as per HPI, ALL OTHERS NEGATIVE
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI.
HEENT: Eyes: No diplopia or blurred vision. ENT: No earache, sore throat or runny nose.
CARDIOVASCULAR: No pressure, squeezing, strangling, tightness, heaviness or aching about the
chest, neck, axilla or epigastrium.
RESPIRATORY: No cough, shortness of breath, PND or orthopnea.
GASTROINTESTINAL: No nausea, vomiting or diarrhea.
GENITOURINARY: No dysuria, frequency or urgency.
MUSCULOSKELETAL: No muscle pain or weakness.
SKIN: No change in skin, hair or nails.
NEUROLOGIC: No paresthesias, fasciculations, seizures or weakness.
PSYCHIATRIC: per HPI, No suicidal or homicidal ideations
ENDOCRINE: No heat or cold intolerance, polyuria or polydipsia.
HEMATOLOGICAL: No easy bruising or bleeding.
MENTAL STATUS EXAMINATION: The patient is alert and oriented. Dress and hygiene are fair.
Looks stated age. Calm and cooperative. Good eye contact. No psychomotor agitation or
retardation. Speech is normal. No pressure of speech. No thought disorder. Thoughts are goal
directed. Affect is euthymic and appropriate. No emotional blunting. The patient denied any
audiovisual hallucinations. No delusions noted. No Suicidal or Homicidal Ideation. Insight and
judgment are fair. Impulse control is fair. The patient is cognitively intact.

Provider Signature

March 17, 2016

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