Physical Exam: Physical exams should be appropriate for the patient and your clinical setting
Physical Exam: Physical exams should be appropriate for the patient and your clinical setting
Submit a psychiatric progress note. You must use an actual patient from your clinical, but remove all identifying information (names, places, etc.) so that it is HIPAA compliant.
You may use the format below for your note, or the format you use at your clinical site.
Psychiatric Patient Progress Note
Demographic data: Do not include identifying information. Must be HIPAA compliant.
Chief complaint:
History of present illness:
Current working diagnoses:
Current psychiatric medications:
Non-psychiatric medications:
Allergies:
Review of Systems: As appropriate, listed by body systems in bullet form
Mental Status Exam:
Physical Exam: Physical exams should be appropriate for the patient and your clinical setting. For example: a telehealth follow up for MDD versus an inpatient psychiatric unit for acute psychosis will have different physical exams.
VS: If obtained
Results: If applicable and results obtained
PHQ9: HAM-A
Labs:
Impression: Narrative discussion of current status and symptoms, how the patient is tolerating the current treatment and any progress toward goals. Also discuss any change in diagnoses or changes to the plan and the reason why. Always discuss the safety evaluation and current safety plan.
Plan:
- Medication orders
- Psychotherapy orders to begin or continue
- Safety orders
- Non-pharmacologic orders – labs, psychoeducation, referrals
- Follow up
Signature: Current credentials, PMHNP student
Requirements: Min 400 words
Nursing
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