Order ID | 53563633773 |
Type | Essay |
Writer Level | Masters |
Style | APA |
Sources/References | 4 |
The perfect number of Pages to Order | 5-10 Pages |
Comprehensive Mental Health Assessment and Treatment Plan
Consent for treatment
Name:
DOB:
Minor:
Accompanied by:
Demographic:
Gender Identifier Note:
Chief Complaint
Reason for the visit, often in the patient’s words
History of Present Illness
Subjective information from the patient.
Description of what the patient wants to be seen for
Mood characteristics
Depression/Anxiety/Panic/Mood instability, etc
Tolerable/Not tolerable
Getting worse or better, if so when did this start
Any stressors that make the condition worse
Are the stressors internal or environmental
When did the patient start manifesting the mood characteristics
Pertinent past history if it pertains to current condition, but it should really only include what is currently happening with the patient.
Things that are exacerbating or alleviating symptoms
SI/HI
Include if the thoughts are passive or active
Intent
Plan
Access to what is needed to complete plan
If HI, do they have a target (consider duty to warn)
Hallucinations/Delusions
If having, what type
How long is it happening
If causing distress
Sleep
Trouble falling asleep
Staying Asleep
Daytime fatigue
Medications
Current medications related to current issue (Prescription, OTC, Supplements)
Side Effects
Effectiveness
Appetite
If patient has multiple issues, what does the patient view as the priority issue to manage
Are they seeing a therapist or any other resource for their current condition
Psychiatric History:
Age of onset
Previous Diagnoses
Past psychotropic history
Past Hospitalizations
Reason for hospitalization
Include dates
Length of stay
Suicide Attempt History
Dates
What they did to attempt
What triggered the attempt
Legal History
Dates
What arrested or in jail for
Trauma History
Physical, Emotional, Sexual or Event
What was the trauma
When did happen
Who performed the abuse if applicable
If they have dealt with the trauma
Substance Use History
Include Past and Present Use
Tobacco
Alcohol
Marijuana
Illicit Substance (ask what substances specifically)
Ask if this has been a problem for the patient in the past and how they have coped with it if they quit
Can also include caffeine if want to
Social History
Include
Born and Raised
Parents married, divorced, separated
Siblings
Childhood (developmental, emotional)
Highest level of education
Employment status (if unemployed, is patient looking for a job)
Relationship status
Children
Living Situation
Social Support
Medical History
Surgical History
Current Medications (All Medications, even if not psychotropics)
Allergies
Family History (Medical and Mental Health)
Review of Systems
OBJECTIVE
Vital signs
Labs
Test results e.g EKGs
Mental Status Exam
Assessment
Screening Tool results if any used
Risk Assessment
Diagnoses (Justify diagnosis and differential diagnosis using DSM -5)
Current
Rule Out
Differential
Plan of Care (This section should be very detailed. I will place an example here. You can modify as you see fit)
The patient denies suicidal or homicidal ideation including intention, method or plan. There are no other safety concerns. This individual is appropriate to be followed in the outpatient clinic. The writer reviewed all of the intake forms as well as the mental health screens. This individual did sign consent forms for treatment as well as the privacy and financial policies.
Regarding medications, medications were discussed in depth at this appointment. We will continue Lexapro 20mg daily for depression and anxiety. We will initiate Abilify 2mg daily at bedtime to augment Lexapro and help with treatment resistant depression, propranolol 10mg TID PRN for anxiety. If patient does not receive relief with Abilify alone, we may consider switching to Effexor at next appointment and cross-titrating with Lexapro. Patient agreed to cut back on drinking, but if continues to have issues with drinking will discuss treatment strategies at next appointment. Risk, Benefits and alternatives regarding medications were discussed with the patient and patient is agreeable to treatment plan. Medications prescribed through ePrescribing.
Writer discussed the importance of psychotherapy related to treatment, patient was referred to an onsite therapist for psychotherapy and CBT.
Patient was instructed to exercise regularly, utilize sleep hygiene, avoid alcohol, illicit substances, and caffeine. Patient advised to practice mindfulness strategies
Writer is recommending patient continue to follow-up with PCP regarding any medical conditions
Patient advised to call 911 or report to emergency room if there is a medical or mental health emergency
Recommend that patient follow-up in 2 weeks
Additional resources were provided to this patient to include handouts with some basic coping skills for when the patient has anxiety, sleep hygiene practices and information on the therapies recommended.
Labs were also ordered at this appointment to include a CBC with Diff, CMP, Lipids, Vitamin B12, Vitamin D, Hemoglobin A1C. May consider additional labs to include UDS, GGT level, Iron Panel if hemoglobin low
Discussions of FDA-approved medications or indication of “off-label” usage are important for treatment plans.
For females, discussion on the effects medication has on birth control, pregnancy, and sexual dysfunction
For males, discussion on sexual dysfunction
Under 25 years old Black box warning for SSRI/SNRI
Billing Codes
Time Spent with patient, therapy time, date
Your name and title
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