TRI-SERVICE WORKFLOW BEHAVIORAL HEALTH SPECIALTY AIM FORM

PEER RECORDS REVIEW– FOLLOW UP VISIT

Date: ______Provider Reviewed: ______Reviewed By: ______

First, Last,Middle Initial
Last 4 SSN / Case #1 / Case #2 / Case #3
Yes / No / N/A / Yes / No / N/A / Yes / No / N/A
Chief Complaint
Documented Time with Patient typed into Chief Complaint Text Box?
Physical Pain Level __/10
Abuse and Neglect Screening
Medication Reconciliation and Compliance
[MD/DO/PMHNP Only]
Statement that “Current Allergies Reviewed”
[MD/DO/PMHNP Only]
Current Medications/OTCs/Supplements/
Herbals
[MD/DO/PMHNP Only]
Psychiatric Medication Tracking
[MD/DO/PMHNP Only]
Substance Use and Treatment History
Tobacco & Nicotine
Alcohol
Caffeine
Illicit/Prescription Drug
Suicide Assessment (“P4”)
Physical Findings[MD/DO/PMHNP Only]
Mental Status Exam (Consists of 2 parts) / 1. General Appearance
2. Psychiatric
Physical Exam
[MD/DO/PMHNP Only] / Relevant data fields are included (e.g., eyes, musculoskeletal system, skin, hair, etc.
Assessment and Diagnosis
Patient Strengths
Patient Obstacles to Treatment
Prognosis
Visit is Deployment-Related?
Therapy (Intervention This Appointment –Cognitive Behavior Therapy (CBT), Medication Treatment, etc.; this applies to all provider types)
Subjective note that includes relevant interim history, progress in treatment, and any potential barriers to treatment to include current stressors
For patients diagnosed with depression PTSD, and other anxiety conditions, are evidenced-based standardized practices being used?[LCSW/PhD/PsyD only]
Is there evidence in that PHP/BHDP data from current visit was reviewed with the patient during the appointment?
Treatment Goals and Objectives
Patient Goals
Treatment Objectives
PHP/BHDP data incorporated intoTx Objectives and Overall Tx Course?
Treatment Plan and Strategy
Medication
Psychotherapy
Referrals
Estimated Frequency and Duration of Treatment
Treatment Options & Education
Tx Plan Collaboratively Discussed
Pt agrees with plan? + Date within 3 months of visit
Risk Level
Safety Plan
Military/Occupational/Legal Actions
Command Notification
Profile Issues
(Fit for Duty, Deployment?)
Legal Problems Noted
Include LIMDU, PEB and any duty restrictions in “Comments:”. This would include restrictions on deployment based on medication changes as well.
A/P Section
DSM5 Diagnosis matches Therapy & PHP/BHDP data?
Disposition
E&M Code selected
Follow-up instructions
Overall
Note completed within 72 hours
Meets Standard of Care

Comments for Provider Reviewed: ______

______

______

DH Actions Taken: ______

______