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: KARON

DOB: not provided

Minor: NA

Accompanied by: self

Demographic: NA

Gender Identifier Note: Female

CC: “I have flashbacks and SI usually early in the morning when I wake up”

.

HPI: the patient reports to the healthcare clinic reporting several symptoms. The patient states that she has been having flashbacks of the last assault, depressed mood. Her insight and judgement are impaired. The patient however denies hallucinations.

Pertinent history in record and from patient: Major depression disorder

During assessment: Patient is calm and corparative. However, the patient’s insight is impaired and judgement impaired. Patient seemed to be suffering from serious cases of both anxiety and despair judging from her crying spells.

Patient denies hallucinating. The patient has nomal thought process. .

SI/ HI/ AV: patient denies 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: NKDA

Describes stable course of illness.

Previous medication trials: not reported

Safety concerns:

History of Violence to Self:none reported

History of Violence t o Others: none reported

Auditory Hallucinations: not reported

Mental health treatment history discussed:

History of outpatient treatment: not reported

Previous psychiatric hospitalizations: not reported

Prior substance 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: the patient does not reports alcohol abuse

Client does report abuse of or dependence on alcohol.

Current Medications: NKDA

(Contraceptives):

Supplements:

Past Psych Med Trials: PTSD

Family Medical Hx: not reported

Family Psychiatric Hx: not reported

Substance use –NKDA

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 fever reported.

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: reports 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: – post-traumatic stress disorder (PTSD) ICD-10 F43.1

Dx: Generalized anxiety disorder ICD-10-CM Code F41.1

Dx: Major depression disorder ICD-10-CM Code F32.1

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. NKDA

Estimated stay

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 patient is put on prazosin 3mg daily until she stablizes.

The course of posttraumatic stress disorder (PTSD) is frequently prolonged, and some individuals may not respond well to antidepressants and cognitive-behavioral therapy (CBT). A1-adrenoceptor blocker prazosin shows some potential for treating recurrent PTSD. After the initial dosage of prazosin for PTSD treatment, blood pressure should be checked often because of the risk of hypotension. After that, the nighttime dosage is progressively raised to a maintenance range of 2–6 mg. When studying PTSD in the military, researchers have often employed much greater dosages (e.g., 10-16 mg at night). Studies in both younger and older persons with PTSD and in patients with alcohol issues have indicated that prazosin reduces cravings and stress reactions. With a rather quick response within weeks, prazosin gives some promise for treating refractory instances of PTSD in which recurring nightmares are bothersome (Bachem, & Casey, 2018).

CBT is also the psychotherapist of choice for dealing with post-traumatic stress disorder (PSTD) (Cooper, 2018). In this phase, the patient and therapist will talk about ways to lessen the severity of the symptoms. Catering to students' emotional, social, and physical well-being as part of their academic curriculum. In addition to medication, psychoeducational therapy for the afflicted person and their family is strongly suggested (Cooper, 2018).

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

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NAME, TITLE

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