Psych Progress Note Late May 2022

Psychiatry Progress Note
Patient Name
Patient ID#
Patient Unit:
DATE OF EXAMINATION

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
TIME OF EXAMINATION

Hour Minutes

AM/PM Option
CPT CODE
Check if Telehealth Service
CHIEF COMPLAINT ("In the patient's own words.")
HISTORY OF PRESENT ILLNESS (To include onset of illness and circumstances leading to admission.)
Past Family and Social History:
New information since last note/visit only:
EXAMINATION
Appearance:
Psychomotor Behavior:
Speech
Attitude
Mood
Affect
Orientation
Perception
Thought Content:
Hallucinations: (Pick here)
Risk Factors
Suicidal:
Describe:
Homicidal:
Describe:
Thought Processes:
Concentration/ Attention Span:
How Tested/Assessed
Recent Memory:
How Tested/Assessed
Remote Memory:
How Tested/Assessed
Intelligence:
How Tested/Assessed
Judgement:
How Tested/Assessed
Insight:
How Tested/Assessed
Explain Abnormal Findings:
Diagnosis/Impressions (from today’s visit):
ASSESSMENT/INITIAL PLAN OF CARE and Medication Consent (as applicable) Patient was provided with detailed information about 1) Proposed medications and dosage range and frequency. 2) The purpose of the treatment. 3) Common short- and long-term side effects of the proposed medication, including contraindications and clinically significant interactions with other medications
Lab Studies, other data, (new/worsening since last visit):
Significant
Pending
Response to Treatment:

Other
Estimated Date of Discharge
Reason for Continued Hospitalization:
Needs prompting for:
Complexity/Risk:
Provider Name:
CLICK HERE AFTER SELECTING PROVIDER NAME
Completed by Scribe?
Scribe Name:
Scribes only:
Your Email
example@example.com
Scribe Signature
Psychotherapy Statement:
At least 16 minutes of this evaluation were spent completing the following psychotherapeutic techniques:
Provider Signature (Sign your Full Name and Credentials):
Supervisor Name
Are you co-signing an NP or PA note?
NP/PA Attestation:
Supervisor Signature (Sign your Full Name and Credentials):
I certify that the above note is ready for printing.
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
  Hour MinutesAM/PM Option
- Provider Last Name
- Provider Email
  example@example.com
- Supervisor Email
  example@example.com
- Ready for Print?
- Patient Name
- Patient Name 3
- Patient Name 4
- Patient ID#
- Patient ID# 3
- Patient ID# 4
- Page Number 1
- Page Number 2
- Page Number 3
- Page Number 4
- Scribe Attestation
- Scribe Attestation Template
  I, ____________________________, am scribing for, and in the presence of, ______________________________.
- Provider for Scribe Attestation:
- NP/PA attestation template
  NP/PA Attestation: I was available to examine the patient to confirm the essential components of the history, physical exam, diagnosis and treatment plan. I agree with the patient's care as documented by the PA/NP.
- Provider Attestation for Scribe
- Provider Attestation for Scribe Template
  I personally performed the services described in this documentation, as scribed in my presence, and it is both accurate and complete.
- Should be Empty:

Psychiatry Progress Note

EXAMINATION

Risk Factors