Psychiatry Follow Up Outpatient Visit & Mental Status Examination
38 Winthrop Place, Staten Island, NY 10314
Date of Service:
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Start Time
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Hour
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Minutes
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AM/PM Option
Patient Name
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First Name
Last Name
Date of Birth:
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Month
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Day
Year
Date
Visit
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Office Visit
Virtual Visit
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Chief Complaint
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Focus of Attention
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Severity
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Mild
Moderate
Severe
Duration
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Less than 1 Year
More than 1 year
Current Stressors
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Family
Work
Social
Medical
I-Stop Performed
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Yes
No
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Family History Original psychiatric evaluation is in medical record
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Yes
No
Past Psychiatric H/X Original psychiatric evaluation is in medical record
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Yes
No
Past Medical/Surgical Original psychiatric evaluation is in medical record
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Yes
No
Social History Update
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Rows
Yes
No
Lives Alone
Family/Children
Employment
Relationships
Medical History Update
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Are you currently pregnant?
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Yes
No
N/A
Consent for use of medications obtained
Yes
No
No Medications Prescribed
Date of last menstrual period
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Month
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Day
Year
Date
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Mental Status Examination
Appearance
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Healthy
Sickly
Limp
Relaxed Posture
Well Groomed
Tense Posture
Unkempt
Poised
Comfortable
Ill at ease
Angry
Anxious
Depressed
Contemptuous
Cooperative
Attentive
Interested
Ingratiating
Seductive
Playful
Apathetic
Guarded
Evasive
Defensive
Hostile
Paranoid
Other
Behavior
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Appropriate
Relaxed
Apathetic
Tense
Rigid
Retarded
Hyperactive
Agitated
Combative
Mannerisms
Tics
Gestures
Other
Speech
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Loud
Monotonous
Emotional
Dysarthic
Slurred
Mumbled
Stutter
Normal
Relaxed
Spontaneous
Slow
Hesitant
Rapid
Pressured
Soft
Other
Mood
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Euthymic
Despairing
Empty
Futile
Guilty
Irritable
Self Contemptuous
Depressed
Awed
Expansive
Euphoric
Anxious
Terrified
Angry
Other
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Affect
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Appropriate
Yes
No
Flat
Broad
Expansive
Constricted
Blunted
Dysphoric
Euphoric
Modulated
Labile
Other
Perceptions
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Depersonalization
Derealization
Hallucinations
Yes
No
Sensory System(s)
Content
Illusions
No Abnormalities
Other
Thought Process
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Goal-directed
Circumstantial
Tangential
Flight of ideas
Loose Associations
Blocking
Perseverations
Confabulation
Distractibility
Incoherent
No Abnormalities
Other
Thought Content
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Preoccupations
Obsessions
Delusions
Suicidal Ideations
Homicidal Ideations
None
No Abnormalities
Other
Cognitive Examination
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Immediate recall
Recent memory
Remote memory
Concentration
Judgment
Abstraction
Intelligence
Orientation
Insight
No Abnormalities
Other
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Suicide
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Yes
No
N/A
Violence
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Yes
No
N/A
Clinician's Response
Called 911
Referred to ER with Family
Safety Plan Accepted By Patient
Call Suicide Hotline
Call Psychotherapist/Family Member
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Goals of Psychotherapy
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Improve understanding of emotional problems
Compliance with medications
Improve coping skills
Improve child-parent relationship
Assistance with cognitive restructuring of negative thoughts
Work on self-esteem issues
Psychoeducation
Behavior Management
Parental Training
Patients Participation
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Active
Passive
Progression Towards Psychotherapy Goals
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Improved
Regressed
No Changes
Partial
Total
Patient's Concerns/Cultural Relevancy/Social Justice
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Medical Decision Making
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Chronic Illness > 1 Year Not Stable
Patient not at Treatment Goal
Acutely Worsening
Poorly Controlled
Progressing with Intent to Control Progression
Addressing Side Effects
Prescription Drug Management
Medical Comorbidity
Medical Necessity / Treatment Plan Update
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Meets Criteria for Active Treatment
Discharge from Treatment on No Medications
Continue Current Treatment Required For
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Symptom Reduction
Improvement in Functioning
Medical Stabilization
Maintenance to Prevent Deterioration
Side Effects to Medication
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Yes
No
Substance Use / Cigarettes / Alcohol Current Use
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Yes
No
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Medical / Dosages
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Current Diagnoses
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1. 2. 3.
Prognosis
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Good
Fair
Guarded
Patient's Concerns / Cultural Relevancy were discussed
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Yes
No
Risks and Benefits of Treatment Options were discussed
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Yes
No
Coordination of Care with PCP / Psychologist / Social Worker
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Yes
No
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REVIEW OF SYSTEMS
Date of Service:
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Month
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Day
Year
Date
Patient's Name:
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First Name
Last Name
1. CONSTITUTIONAL: No fever. No chills. No dizziness. No weakness.
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2. EYES: No pain, erythema, or discharge. No blurring of vision.
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3. ENT: No sore throat, URI symptoms. No epistaxis. No tinnitus.
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4. CARDIOVASCULAR: No chest pain. No palpitations. No lower extremity edema.
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5. RESPIRATORY: No shortness of breath, cough, pain with respiration, pleuritic chest pain. No hemoptysis. No dyspnea. No paroxysmal nocturnal dyspnea.
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6. GASTROINTESTINAL: Normal appetite. No nausea, vomiting, diarrhea. No pain. No bloating. No melena.
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7. GENITOURINARY: No frequency, urgency, nocturia. No hematuria or dysuria.
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8. MUSCULOSKELETAL: No arthralgias or myalgias.
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9. INTEGUMENTARY: No swelling. No bruising. No contusions. No abrasions. No lymphangitis.
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10. NEUROLOGIC: No headache. No neck pain. No numbness or tingling of the extremities. No weakness.
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11. PSYCHIATRIC: No confusion. See mental status examination attached.
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12. ENDOCRINE: No fatigue. No weakness. No history of thyroid, diabetes or adrenal problems.
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13. HEMATOLOGICAL: No bleeding. No petechiae. No bruising.
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14. ALLERGIES: No asthma. No urticaria. NKDA.
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Clinician Name:
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Olga Katz, M.D.
Svetlana Beskina, D.O.
Detty Darly, NP-P
Phanessa Jean, NP-P
Yelena Anbinder, NP-P
Alexis Sciarrino, PMHNP-BC
Yelena Shvets, PMHNP-BC
Diloram Kamilova, PMHNP-BC
Pleah Nahari, PMHNP-BC
David Jobczynski, PMHNP-BC
Roberto De Paula, M.D.
Signature
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