STK Template - Initial

Reason for Appointment

[Document the patient's stated reason for the appointment, including any specific symptoms or concerns they express.]

History of Present Illness

[Provide a highly detailed narrative of the patient's current illness, including the referral source, identifying information, and source of information. Include a comprehensive history of present illness (HPI) with details about the onset, duration, and nature of symptoms, any significant life events, and the patient's account of their condition. Ensure to include any relevant psychiatric history, such as depression, mania, anxiety, psychosis, suicidal and homicidal ideation, sleep problems, and substance use. Always address any sexual dysfunction or changes in libido, and any forms of physical, verbal, psychological, financial, or sexual abuse or assault if these topics are discussed or mentioned in the patient's history.]

Current Medications

[List any current medications the patient is taking, including dosage and frequency.]

Past Medical History

[Verify and document the patient's past medical history, including any significant medical or surgical history.] **Psychiatric History:** Include psychiatric hospitalization, past medications taken, effects of medications, side effects, sexual dysfunction, efficacy, reason for discontinuation, history of self-harm, suicide attempt, and method of attempt.

Family History

[Document the family history, including the health status of immediate family members, any relevant hereditary conditions, and specifically note any psychiatric family history, including hospitalization, suicide, alcohol abuse, and substance abuse.]

Social History

[Provide a detailed account of the patient's social history, including tobacco and alcohol use, drug use, caffeine intake, exercise habits, living situation, marital status, support systems, and any history of abuse or domestic violence.]

Allergies

[List any known drug allergies or other allergies the patient has.]

Review of Systems

[Conduct a comprehensive review of systems, documenting any positive or negative findings across various bodily systems, including general, allergy/immunology, ophthalmologic, ENT, endocrine, respiratory, cardiovascular, gastrointestinal, hematology, genitourinary, musculoskeletal, skin, neurologic, and psychiatric systems.]

Chief Complaint

Psychiatric Evaluation for Anxiety and Depression

Depression Screening

[Document the results of any depression screening tools used, such as the PHQ-9, including individual item responses, total score, and interpretation of the results.]

Hospitalization/Major Diagnostic Procedure

[Document any past hospitalizations or major diagnostic procedures the patient has undergone.]

Vital Signs

[Record the patient's vital signs, including temperature, heart rate, blood pressure, weight, BMI, height, respiratory rate, and oxygen saturation.]

Examination

[Conduct a general physical examination and document findings, including general appearance, head, eyes, ears, oral cavity, throat, neck/thyroid, skin, heart, lungs, chest, abdomen, extremities, and neurologic status.]

Mental Status Exam

[Perform a mental status examination and document findings, including orientation, appearance, weight, gait, posture, psychomotor activity, memory, thought process, thought content, speech, mood, affect, registration, attention, and recall.]

Assessments

[List the patient's diagnoses, including primary and secondary conditions, with their corresponding medical codes.]

Treatment

[Outline the treatment plan for each diagnosis, including medication prescriptions, dosage, frequency, and any clinical notes regarding the treatment plan. Include any psychotherapy services provided and therapy goals.]

Preventive Medicine

[Document any preventive wellness plans, including recommended screening frequencies and the dates of the last screenings for conditions such as depression and alcohol misuse.]

Care Plan

- [Summarize the care plan discussed with the patient in simple language.] - **Medication Instructions:** - [List each medication prescribed, including the name, dosage, and frequency of administration.] - **Follow-Up Appointments:** - [Provide details of any scheduled follow-up appointments, including date, time, and location.] - **Additional Recommendations:** - [Include any lifestyle changes or additional steps the patient should take to manage symptoms effectively.]