What is an example of a psychiatric office visit note template?

Updated: Sep 24, 2020
  • Author: Jeffrey S Forrest, MD; Chief Editor: David Bienenfeld, MD  more...
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Answer

Answer

Name:

Date of Visit:

Age:

DOB:

Race: A B H W O

Sex : M F Height : Weight:

Allergies:

Current Medications:

1.

2.

3.

4.

5.

6.

Medication Problems / Concerns / Side Effects: No

Yes:

Effectiveness of Medications: High Medium Somewhat Low None

Compliance with Prescribed Medications: High Medium Low Noncompliant

Subjective

Sleep

Anhedonia

Guilt

Weight

Concentration

Energy

Anger

Substance Use

Anxiety

Aud. Hall.

Vis. Hall.

Delusions

Impulsivity

Other

No Additional Problems Reported

Objective

Appearance

Grooming

Hygiene

Eye Contact

Facial Expression

Mood

Affect

SI

HI

Plans

Insight

Judgment

Reliability

Progress Toward Goals: None Some Moderate Significant Completed New

Goal:

Assessment

Based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5) criteria.

Problem List Goals

Plans:

Medications: Continue above medication(s)

Discontinue

Increase:

Decrease:

Risk / Benefit / Side Effects / Alternatives Discussed / Informed Consent Obtained

For:

Intervention Therapy

Other:

Education / Instructions: If condition changes report to ER Medications Illness Coping / Problem Solving Skills

Nutritional Health Maintenance Other:

Referral: PCP Ob/Gyn Neurologist Other:

Return to Clinic: Week(s) Month(s)

LAB Ordered: Misc:

Patient Verbally Acknowledged Understanding and Agreed with the Aforementioned Treatment Plan.

Signature, Date


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