Criteria

Clinical Notes

Informed Consent

Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion)

Subjective

Verify Patient

Name: JD

DOB: not provided

Minor: NA

Accompanied by: self

Demographic: NA

Gender Identifier Note: Female

CC: “husband poisoned me and I am going to get fired from my job for breaching security”

.

HPI: An individual of the feminine gender presents themselves as a patient. Bipolar disorder has run in the client's family. She seemed to be suffering from serious cases of both anxiety and despair. She had begun to experience delusions and other symptoms of dementia. The complaining patient claimed her spouse was poisoning her and that she would be fired for violating security procedures at work. We were able to determine that she was severely delusional after consulting with her social worker, her workplace, and her family. The person was on Effexor.

Pertinent history in record and from patient: Bipolar

During assessment: Patient is delussional and cannot express herself logicall.

Patient seemed to be suffering from serious cases of both anxiety and despair.

Patient is hallucinating . A deviation from typical behavior in the patient's energy, focus, and concentration levels was noted. .

SI/ HI/ AV: famiy says that the patient shows signs of suicidal ideation and violent behavior.

Allergies: NKDFA.

(medication & food)

Past Medical Hx:

Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.

Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.

Surgical history no surgical history reported

Past Psychiatric Hx:

Previous psychiatric diagnoses: Bipolar

Describes stable course of illness.

Previous medication trials: Effexor

Safety concerns:

History of Violence to Self:none reported

History of Violence t o Others: none reported

Auditory Hallucinations: present

Mental health treatment history discussed:

History of outpatient treatment: reported

Previous psychiatric hospitalizations: not reported

Priorsubstance abuse treatment: not reported

Trauma history: Client reveals no history of traumatic experiences (such as abuse, domestic violence, or exposure to upsetting events).

Substance Use: nor reported

Client does not report abuse of or dependence on ETOH, and other illicit drugs.

Current Medications: Effexor.

(Contraceptives):

Supplements:

Past Psych Med Trials: Bipolar

Family Medical Hx: not repported

Family Psychiatric Hx: not reported

Substance use –not repoted

Suicides-not reported

Psychiatric diagnoses/hospitalization-not reported

Developmental diagnoses

Social History:

Occupational History: currently unemployed.

Military service History:Denies previous military hx.

Education history: completed HS and vocational certificate

Developmental History: no significant details reported.

(Childhood History include in utero if available)

Legal History: no reported/known legal issues,no reported/known conservator or guardian.

Spiritual/Cultural Considerations: none reported.

ROS:

Constitutional: No report of fever or weight loss.

Eyes: No report of acute vision changes or eye pain.

ENT: No report of hearing changes or difficulty swallowing.

Cardiac: No report of chest pain, edema or orthopnea.

Respiratory: Denies dyspnea, cough or wheeze.

GI: No report of abdominal pain.

GU: No report of dysuria or hematuria.

Musculoskeletal: No report of joint pain or swelling.

Skin: No report of rash, lesion, abrasions.

Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia.

Hematologic: No report of blood clots or easy bleeding.

Allergy: No report of hives or allergic reaction.

Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)

Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo.

Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview.

HPI:

, Past Medical and Psychiatric History,

Current Medications, Previous Psych Med trials,

Allergies.

Social History, Family History.

Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”

Objective

Vital Signs: Stable

This is where the “facts” are located.

Vitals,

**Physical Exam (if performed, will not be performed every visit in every setting)

Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.

Assessment

DSM5 Diagnosis: with ICD-10 codes

Dx: – Bipolar disorder CD-10-CM Code F31

Dx: – Major depressive disorder ICD-10-CM Code F33.2

Dx: – – Post Traumatic Stress Disorder F43.12

Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent.

Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.

Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.

Informed Consent Ability

Plan

(Note some items may only be applicable in the inpatient environment)

Inpatient:

Psychiatric. Admits to Bipolar as per HPI.

Estimated stay 3-5days

Safety Risk/Plan: Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time.

Patient denies abnormal perceptions and does not appear to be responding to internal stimuli.

Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic:

The initial medication was changed. the patient is put on abilify 10gm until she stablizes.

or… Mood stabilizers like lithium (Lithobid), antipsychotics like olanzapine (Zyprexa), and antidepressant/antipsychotic combos like fluoxetine/olanzapine (Symbyax) are among the most often prescribed medications for this condition the patient can start lithobid 50mg and move to 100 week 6-8. f/u within 2 weeks initially then every 6-8 weeks (Carvalho, et al., 2020).

Psychotherapy referral for CBT. One of the recommended non-pharmacological therapies for this illness is cognitive-behavioral therapy. Here, both the patient and therapist will talk about methods the patient may use to control their symptoms.

Education, including health promotion, maintenance, and psychosocial needs

Importance of medication- The patient and their loved ones will benefit from receiving psychoeducational therapy for this condition. If you and others around you want to better manage bipolar illness, learning more about it may be helpful (McIntyre, et al., 2020).

Referrals: CBT

Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 4 weeks

☒>50% time spent counseling/coordination of care.

Time spent in Psychotherapy 18 minutes

Visit lasted 55 minutes

Billing Codes for visit:

XX

XX

XX

____________________________________________

NAME, TITLE

Date: Click here to enter a date.Time: X