Follow-up Psychiatric Evaluation Note Template

CHIEF COMPLAINT

“[Patient’s own words]”

PRESENT ILLNESS

[Patient Name] is a [Age] [Identified Gender] who lives in [Dwelling Type] with past history of [Psychiatric then Medical Diagnoses] who presents today for follow up for [Past Diagnoses] [Write a narrative that features: - Chronological progression of symptoms including onset, duration, and trajectory - Note any triggers or precipitating factors - Document specific symptoms with examples - Include frequency and severity of symptoms - Document response to treatment already tried - Note impact on functioning (work, relationships, ADLs) - Include any current or recent treatment/medications - Document any recent hospitalizations or ED visits - Note any history of self-harm or suicide attempts] Medications Adherence: [Complete or document reasons why not adherent] Medication Side Effects: [Reported side effects]

Psychiatric Review of Systems

Safety: Endorses: [Reported Symptoms] Denies: [Pertinent Negatives] Depression: Endorses: [Reported Symptoms] Denies: [All other symptoms of this diagnosis that were not reported] Mania: Endorses: [Reported Symptoms] Denies: [All other symptoms of this diagnosis that were not reported] Psychosis: Endorses: [Reported Symptoms] Denies: [All other symptoms of this diagnosis that were not reported] Anxiety/Panic: Endorses: [Reported Symptoms] Denies: [All other symptoms of this diagnosis that were not reported] Trauma: Endorses: [Reported Symptoms] Denies: [All other symptoms of this diagnosis that were not reported] OCD: Endorses: [Reported Symptoms] Denies: [All other symptoms of this diagnosis that were not reported]

CURRENT SUBSTANCE USE

Alcohol: [Denies or endorses with frequency and last use] Cannabis: [Denies or endorses with frequency and last use] Stimulants: [Denies or endorses with frequency and last use] Sedatives: [Denies or endorses with frequency and last use] Opioids/Opiates: [Denies or endorses with frequency and last use] Hallucinogens: [Denies or endorses with frequency and last use] Tobacco: [Denies or endorses with frequency and last use] Caffeine: [Denies or endorses with frequency and last use]

PSYCHOSOCIAL

[Document relevant psychosocial history]

MEDICAL HISTORY

[Document relevant medical history]

ALLERGIES

[List allergies]

CURRENT MEDICATIONS

[List current medications]

Chief Complaint

Follow-up Psychiatric Evaluation Note Template

Labs

I have reviewed the patient's labs within the last 24 hours. [Review the patient's labs conducted within the last 24 hours. Include any new labs, summarize results that are unremarkable, and note any pending results.]

Diagnostic

[Provide a summary of any new or existing radiology findings. If no new radiology is available, state "No new radiology." Include details about any relevant imaging studies, their results, and any changes from previous findings.] I have reviewed the patient's radiology report(s) within the last 24 hours

Physical Examination

[Constitutional: Describe the patient's general appearance, nutritional status, and any signs of distress.] [Head: Note the shape and condition of the head, including any trauma.] [Eyes: Evaluate extraocular movements and check for any conjunctival discharge.] [Neck: Assess the range of motion.] [Pulmonary/Chest: Observe for any signs of respiratory distress.] [Neurological: Identify any focal deficits and assess orientation to person, place, and time.] [Skin: Check for diaphoresis.]

Mental Status Examination

Appearance: [Well-groomed, adequately groomed, disheveled, malodorous, unusual dress, appears stated age, appears younger/older than stated age, obese, thin, cachectic, physical disabilities noted, distinguishing features] Behavior and Reliability: [Cooperative, uncooperative, hostile, guarded, defensive, dramatic, withdrawn, agitated, restless, psychomotor retardation/agitation, catatonic features, reliable historian, poor historian, inconsistent historian] Speech: [Normal rate/volume/tone, pressured, loud, soft, mumbled, slurred, monotone, stilted, tangential, circumstantial, paucity, mute] Mood: ["Quote patient's subjective report"] Affect: [Euthymic, depressed, anxious, irritable, angry, euphoric, labile, full range, restricted, blunted, flat, congruent/incongruent with mood, appropriate, inappropriate, labile] Thought Process: [Logical, goal-directed, circumstantial, tangential, flight of ideas, loose associations, word salad, blocking, perseveration, concrete, abstract] Thought Content: [No SI/HI/delusions/paranoia, suicidal ideation (passive/active, with/without plan/intent), homicidal ideation (passive/active, with/without plan/intent), delusions (persecutory/grandiose/somatic/reference/control), paranoia, obsessions, phobias, ideas of reference] Insight: [Good/fair/poor/absent, aware of illness/situation, understands need for treatment] Judgment: [Good/fair/poor/impaired, able to make reasonable decisions, understands consequences of actions] Memory: [Recent and remote intact, recent impaired, remote impaired, immediate recall impaired, confabulation present] Attention and Concentration: [Maintained throughout interview, easily distracted, poor concentration, unable to focus] Language: [Fluent, no aphasia, word-finding difficulty, paraphasia, neologisms, echolalia] Fund of Knowledge: [Intact, impaired, current events knowledge, cultural knowledge, educational level appropriate]

INFORMED CONSENT

Patient is able to provide informed consent: [Yes/No] Is the patient safe to remain at current level of care: [Yes/No] Does the patient have a conservator? [Yes/No]

Suicide Risk Assessment

Psychiatric Disorder(s): Axis I and Axis II: [Past and current disorders] Key Clinical Considerations: [E.g. Intense psychological pain/anguish, agitation, anxiety/panic, physical pain, anhedonia, impulsivity, hopelessness, command hallucinations, worthlessness, intense self‐loathing, excessive guilt, feeling that death would bring relief, executive functioning deficits, relationship difficulties, status of important connections] Suicidal Behavior: [History of prior attempts, self‐injurious behaviors, attempts in hospital, writing/talking/ruminating about death] Family History Psychopathology [History of suicidality and major mental illness, abuse and neglect] Precipitants/Stressors: [Triggering events, e.g. loss of or threat of loss of relationship, recent deaths, medical illness, public/social humiliation, exposure to trauma, legal or financial difficulties] Access to Firearms/Other Lethal Means: [Current]

Internal and External Factors:

Internal: [Provide details on the patient's ability to cope with stress, religious beliefs, frustration tolerance, and sense of hope.] External: [Include information on the patient's responsibility to children/pets, social supports, specifically positive connections, and therapeutic relationships.]

Suicide Inquiry

Ideation: [Detail the frequency, intensity, and duration of suicidal thoughts, including recent occurrences and the worst ever experienced.] Plan: [Describe the timing, location, lethality, availability, and preparation of any suicide plan.] Behavior: [Include past attempts, aborted attempts, rehearsals (e.g., tying noose, loading gun), suicide notes, obtaining lethal implements/equipment, stockpiling medication, and researching suicide methods on the internet.] Intent: [Explain the extent to which the patient believes the plan is lethal, their expectation to carry out the plan, their wish to die, and any regrets about survival.]

Risk Assessment

[Assess the current risk to self and select the appropriate level: Low, Moderate, or Elevated.] Current risk to self is assessed to be: [ ] Low [ ] Moderate [ ] Elevated [Assess the chronic risk and select the appropriate level: Low or Elevated.] Chronic risk is assessed to be: [ ] Low [ ] Elevated

Risk Migitation

[Provide a detailed list of steps taken to address dynamic and clinical risk factors. Include any considerations of historical risk factors in the overall risk assessment. Use a narrative paragraph style to describe the mitigation strategies and considerations.] Note: Historical risk factors cannot be mitigated but have been considered in overall risk assessment.

Plan

[For each DSM-5TR Diagnosis, provide a detailed plan including the following sections:] [DSM-5TR Diagnosis]: - Current Symptoms: [Describe the current symptoms related to the diagnosis.] - Response to Treatment: [Summarize the patient's response to any treatments provided.] - Recommendations: [Provide recommendations for future treatment or management.] Level of care: [Indicate the appropriate level of care, e.g., "Appropriate for continued outpatient work."] Medications: - Continue [Current Medications]: [List medications to be continued.] - [Any changes should be ALL CAPS: starting dose, titration schedule] - Discussed most common side effects which include [List side effects of each medication discussed.] - [Required monitoring through labs and EKG] [Repeat the above structure for any Secondary DSM-5TR Diagnosis if applicable.]