Initial Visit

Initial Patient Visit Form

The Psychiatry Group PLLC Phone: 844-495-4357


Patient Name

Date

Source of info

History


CHIEF COMPLAINT/REASON FOR ENCOUNTER

HPI(1-3 elements - Brief; 4+ elements – Extended )

Elements:

Location

Quality

Severity

Duration

Timing

Content

Modifying Factors

Associated Signs & Symptoms

PAST PSYCHIATRIC HISTORY: (1 history area – Pertinent; 2-3 history areas – Complete)

PAST MEDICAL HISTORY:

Diagnoses

Medications

Surgeries

Allergies

PAST FAMILY, SOCIAL, HISTORY (PFSH)

REVIEW OF SYSTEMS & ACTIVE MEDICAL PROBLEMS,NOTES IF POSITIVE

(1 system - Problem Pertinent; 2-9 systems – Extended; 10 or more systems or some systems noted as "all others negative"- Complete)

1.Constitutional

 pos neg

2.Eyes

 pos neg

3.Ears/Nose/Mouth/Throat

 pos neg

4.Cardiovascular

 pos neg

5.Respiratory

 pos neg

6.Gastrointestinal

 pos neg

7.Genitourinary

 pos neg

8.Muscular

 pos neg

9.Integumentary

 pos neg

10.Neurological

 pos neg

11.Endocrine

 pos neg

12.Hematologic /Lymphatic

 pos neg

13.Allergies/Immune

 pos neg

PSYCHIATRIC SPECIALTY EXAMINATION


(1-5 bullets- Problem Focused; at least 6 bullets Expanded Problem Focused; at least 9 bullets - Detailed; all bullets- Comprehensive Exam)

Patient personally examined: yes no

• Vital Signs (any 3 or more of the 7 listed):

Blood Pressure: (Sitting/Standing)

(Supine)

Temp

Pulse(Rate/Regularity)

Respiration

Height

Weight

General Appearance and Manner: (e.g., development, nutrition, body habitus, deformities, attention to grooming)

Musculoskeletal: Assessment of muscle strength and tone(e.g., flaccid, cog wheel, spastic) (note any atrophy or abnormal movements) Examination of gait and station

Speech normal

Rate

Volume

Articulation

Coherence

Spontaneity

Thought processes  normal

Associations

Processes

Abstraction

Computation

Description of associations

(e.g., loose, tangential, circumstantial, intact)

Description of abnormal or psychotic thoughts (e.g., hallucinations, delusions, preoccupation with violence, homicidal or suicidal
ideation, obsessions)

Suicidal ideation:

 Present Absent

Homicidal ideation:

 Present Absent

Violent ideation:

 Present Absent

Description of patient's judgment and insight

Orientation

Memory (Recent/Remote)

Attention/Concentration

Language

Fund of knowledge

 intact inadequate

Mood and affect

Other Findings (e.g. cognitive screens, etc.)

MEDICAL DECISION MAKING


Need for admission/evaluation:

Medical Records/Labs/Diagnostic Tests Reviewed:

Diagnoses


Axis I-V:

Rule outs:

Formulation:

Treatment Plan


Intervention/Psychotherapy

Medication

Labs/Radiology/Tests/Consultation

Other

Greater than 50% of time spent in counseling/coordination of care (document)