99231 Psychiatric Care Progress Note - Face to Face
99231 Psychiatric Care Progress Note - Face to Face
SERVICE DATE:
TIME SPENT ON UNIT IN MINUTES (Required):
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Lamb Warning Given: Yes
Prior to my interview with the patient, I told the patient that I am a Psychiatric Nurse Practitioner meeting with him/her for the purpose of treatment/evaluation. I also stated that if I ever need to testify in court about him/her, our conversations would not be privileged or confidential. I also told the patient that he/she did not have to participate in the interview that he/she could end the interview, and that he/she did not have to answer certain questions if he/she did not want to do so. The patient understood that I might be testifying in court at a future date.
He/she stated: “X”
In my opinion, the patient understood the reason for our meeting, the limits of confidentiality and the voluntary nature of his/her participation.
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CHIEF COMPLAINT/PRESENTING PROBLEM
Primary complaint(s):
[] increased stress / [] depressed mood / [] substance abuse[] anxiety / [] suicidality / [] perceptual disturbances
[] panic attacks / [] mood lability / [] thought disturbances
[] poor concentration / [] manic symptoms / [] interpersonal conflict
[] insomnia / [] impulsivity / [] side effects from medications
[] other:
Patient states “X”.
Review of Symptoms
Overall Functioning: no complaint Note:
Sleep: no complaint Note:
Appetite: no complaint Note:
Energy: no complaint Note:
Movement: no complaint Note:
ADLs: no complaint Note:
Concentration: no complaint Note:
Social Interactions: no complaint Note:
Depressive Symptoms: no complaint Note:
Manic Symptoms: no complaint Note:
Behavioral Symptoms: no complaint Note:
Anxiety Symptoms: no complaint Note:
Panic Symptoms: no complaint Note:
Psychotic Symptoms: no complaint Note:
Cognition: no complaint Note:
Substance use related issues: no complaint Note:
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History of Present Illness
HISTORY OF PRESENT ILLNESS
[XX]-year-old [employment status] [marital status] [Caucasian] [gender] with [diagnoses], here under Section # due to expire on [Expiration Date].
Patient has displayed stable but symptomatic mental status, has been visible on the unit with frequent appropriate social interactions with peers and staff. Patient is actively participating in offered treatment groups and is consistently adherent with prescribed medications.
Staff report “X”
As of our last interaction, patient denies mood symptoms. Patient denies psychotic symptoms, including delusional beliefs and perceptual disturbances. Patient denies current thoughts of harm to others and denies current thoughts of harm to self. Patient appears to be at no/minimal risk of engaging in high-risk behaviors.
Psychosocial Factors (Quality): no reported significant events/life changes reported by patient/care providers
Timing of Reported Symptoms:
[] daily/constant / [] acute onset / [] worse in morning / [] postpartum[] nearly every day / [] gradual onset / [] worse in evening / [] seasonal
[] more than half the time / [] variable / [] situational / [] anniversaries
[] infrequent / [] chronic / [] when triggered
Context:
no reported legal issues
no reported life stressors
no reported current medical concerns
no reported recent loss(es)
Modifying Factors:
[] psychotropic medication(s) / [] herbal supplements / [] therapeutic groups[] psychotherapy / [] spiritual coping / [] social support
[] non-pharmacological tx / [] other:
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RISK ASSESSMENT
no report of suicidal ideation -
no report of self-harm urges/behaviors
no report of homicidal/violent ideation -
Risk Behaviors:
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HISTORY
Legal History:
-
Family History: No reported changes from last evaluation
Social History: No reported changes from last evaluation
Additional Information: N/A
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MEDICATIONS
Allergies: NKDA
Current Medications:
[] Acetaminophen 650mg PO q6 hours PRN - general pain[] Alamag Plus 20mL PO q6hours PRN - dyspepsia
[] Milk of Magnesia 30mL PO QHS PRN - constipation
[] Nicotine Replacement Therapy:
[]
[]
[]
[]
[] Tolerating without any reported side effects
[] Reports adverse reaction, specifically: N/A
Side Effects:
Medication adherence: N/A
Overall efficacy of current psychotropic regimen: N/A
Medication changes:
N/A
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MEDICAL
Medical Concerns: No new complaints reported by patient/care providers
Wellness: No specific health promotion behaviors reported by patient/care providers
Labs/Tests: No new results reported; Ongoing Monitoring: N/A
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MENTAL STATUS EXAM
Vital Signs (3/6): BP - N/A HR - N/A RR - N/A Temp - N/A Height – X Weight – X lbs
Appearance: ASA , appropriate attire, well-groomed, appropriate hygiene, average build, average height
Attitudes and Behavior: calm, pleasant, cooperative, appropriate eye contact, abnormal gestures/mannerisms not observed
Muscle tone and Strength: appears WNL, not formally tested
Gait and Station: steady gait, erect posture
Mood: “x”
Affect: euthymic, full, even, congruent with stated mood, appropriate to situation
Speech: spontaneous, normal rate, appropriate volume/tone, fluent
Language: no problems expressing self, able to comprehend questions
Ideation: no voiced delusions, no voiced bizarre content, no voiced suspiciousness
Perception: no voiced AH, no voiced VH, no voiced command hallucinations
Thought Process: linear, coherent, goal-directed
Thought Content: no abnormal content elicited, no voiced paranoia
Suicide Assessment: denies current ideation
Homicide/Violent Ideation: denies current ideation
Impulsivity: low risk, considering current presentation and past history
Sensorium and Cognition
Level of Consciousness: alert
Patient Orientation: fully oriented
Ability to Recall: normal
Memory Description: recent events: intact, remote events: intact
Attention/Concentration: appropriate, able to recall details of prior meeting
Abstract Thinking: intact, not formally tested
Fund of Knowledge: average
Estimated Intelligence: average, vocabulary fluent
Reliability: appears adequate
Judgment: fair
Insight: fair
Additional Findings:
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DIAGNOSIS:
[INSERT HERE]
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DELIVERY OF CARE
Medical Decision Making
[] Minor Problem: -
[] Established Problem: -
[] New problem: -
Patient/Family counseled on:
[] prognosis / [] risk/benefit of treatment / [] risk factor education[] psychoeducation: / [] other:
[] Reviewed chart: (findings noted above)
Discussed with: [] Nursing [] Social Work [] MHW [] OT/Rehab [] Forensics [] Psychologist
[] Case Manager [] Family [] Administration [] Other:
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ASSESSMENT (Required):
[XX]-year-old [employment status] Caucasian [marital status] [gender] with current diagnosis of [diagnoses], admitted to WRCH from [Facility] on [Admission Date] under Section 16b for commitment for treatment due to expire on [Expiration Date] on charges of [charges] was referred for symptoms/behaviors.
Patient reports mood as “quote”, denies mood symptoms. Patient denies anxiety issues. Patient denies psychotic symptoms, including delusional beliefs and perceptual disturbances.
Patient is found to be stable and appears to have control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time.
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PLAN (Required):
Action Plan:
- Observation status: 30 min for safety
- No changes to current diagnoses at this time
- No changes to current medications at this time
- Risks vs. benefits of ongoing treatment with psychoactive medications were assessed and benefits outweigh risks. Discussed appropriate Black Box Warnings, possible alternatives, including non-pharmacological approaches.
Psychopharmacology Treatment Plan:
- Continue to diagnostically assess and adjust medications as needed
- Attain and maintain symptom remission
- Monitor efficacy, tolerance and adverse effects of medications
- Perform appropriate diagnostic testing as needed
- Collaborate with other care providers/organizations to ensure continuity of treatment as appropriate