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    Generic Normal Psychiatric Established-Patient Med Check

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    keisha
    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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    Generic Normal Psychiatric Established-Patient Med Check

    Uploaded by

    keisha
    59 views2 pages
    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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    psychiatric progress report/medication review normal

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    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.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    59 views2 pages

    Generic Normal Psychiatric Established-Patient Med Check

    Uploaded by

    keisha
    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.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 2

    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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