Special Needs Progress Note -Clinician
Precision Psychiatric Services
Patient's Name
Date of Evaluation
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Other
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Status since last appointment:
Describe interventions used or taught during session:
Current Status:
Medication Adherent?
Yes
No
N/A
Suicidal Ideations Noted?
Yes
No
Refused to answer
Homicidal Ideations Noted?
Yes
No
Refused to answer
Mental Status Exam
Appearance:
Appropriate
Meticulous
Unclean
Disheveled
Other
Speech:
Appropriate
Expressive
Loud
Slowed
Pressured
Slurred
Other
Mood:
Appropriate
Depressed
Euphoric
Anxious
Angry
Irritable
Other
Affect:
Appropriate
Tearful
Blunted
Flat
Labile
Hostile
Other
Thought Process:
Coherent
Circumstantial
Tangential
Loose Associations
Poverty of Thought
Flight of Ideas
Other
Thought Content:
Appropriate
Auditory Halucinations
Visual Hallucinations
Obsessive
Delusional
Suicidal Ideations
Homicidal Ideations
Other
Orientation:
Person
Place
Time
Situation
Intelligence:
above average
average
below average
well below average
Memory:
Intact
Immediate impaired
Recent impaired
Remote impaired
Insight:
Good
Fair
Poor
Judgement:
Good
Fair
Poor
Behavior:
Appropriate
Belligerent
Agitated
Impulsive
Withdrawn
Other
Diagnosis:
PLAN:
Continue SN Visits
Homework given
Start suicide watch
D/C from SN program (needs f/u in 30 days)
Consult with Psychiatrist
Consult with Correctional Staff
Consult with Psychologist
Other
Referred to
Medical
Psychiatric Provider
Discharge planner
Other
Should be seen by psychiatry within ( ) days:
Follow up in:
2 weeks
3 weeks
30 days
45 days
60 days
Other
Clinician Name
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: