99231 Psychiatric Progress Note - Coordination of Care

SERVICE DATE: DATE

TOTAL TIME IN UNIT/ON FLOOR (Required): # minutes

(Counseling/coordinating care in mins. is greater than 50% of unit/floor time)

DISCIPLINES CARE COORDINATED WITH (Required): [] SW [] RN [] LPN [] MHW

[] Psychologist [] OT/Rehab [] Case Manager [] Family [] Others:

CARE COORDINATED SUMMARY (Required):

[]Met patient individually to assess mental status. [] Discussed case with care providers.

[] Reviewed treatment and disposition plans with treatment team.

[] Reviewed safety, medications, and health/wellness.

[] Other:

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Lamb Warning Given: N/A

Prior to my interview with the patient, I told the patient that I am a Psychiatric Nurse Practitioner meeting with him/her for the purpose of treatment/evaluation. I also stated that if I ever need to testify in court about him/her, our conversations would not be privileged or confidential. I also told the patient that he/she did not have to participate in the interview that he/she could end the interview, and that he/she did not have to answer certain questions if he/she did not want to do so. The patient understood that I might be testifying in court at a future date.

He/she stated: N/A

In my opinion, the patient understood the reason for our meeting, the limits of confidentiality and the voluntary nature of his/her participation.

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CHIEF COMPLAINT/PRESENTING PROBLEM

Primary complaint(s):

[] increased stress / [] depressed mood / [] substance abuse
[] anxiety / [] suicidality / [] perceptual disturbances
[] panic attacks / [] mood lability / [] thought disturbances
[] poor concentration / [] manic symptoms / [] interpersonal conflict
[] insomnia / [] impulsivity / [] side effects from medications
[] other:

Statement:X

Review of Symptoms

Overall Functioning: no complaint Note:

Sleep: no complaint Note:

Appetite: no complaint Note:

Energy: no complaint Note:

Movement: no complaint Note:

ADLs: no complaint Note:

Concentration: no complaint Note:

Social Interactions: no complaint Note:

Depressive Symptoms: no complaint Note:

Manic Symptoms: no complaint Note:

Behavioral Symptoms: no complaint Note:

Anxiety Symptoms: no complaint Note:

Panic Symptoms: no complaint Note:

Psychotic Symptoms: no complaint Note:

Cognition: no complaint Note:

Substance use related issues: no complaint Note:

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History of Present Illness

[XX]-year-old [employment status][marital status][Caucasian][gender] with [diagnoses], here under Section # due to expire on [Expiration Date].

Patient has displayed stable but symptomatic mental status, has been visible on the unit with frequentappropriatesocial interactions with peers and staff. Patient is activelyparticipating in offered treatment groups and is consistentlyadherent with prescribed medications.

Staff report “X”

As of our last interaction, patient denies mood symptoms. Patient denies psychotic symptoms, including delusional beliefs and perceptual disturbances. Patient denies current thoughts of harm to others and denies current thoughts of harm to self. Patient appears to be at no/minimalrisk of engaging in high-risk behaviors.

Psychosocial Factors (Quality):no reportedsignificant events/life changes reported by patient/care providers

Timing of Reported Symptoms:

[] daily/constant / [] acute onset / [] worse in morning / [] postpartum
[] nearly every day / [] gradual onset / [] worse in evening / [] seasonal
[] more than half the time / [] variable / [] situational / [] anniversaries
[] infrequent / [] chronic / [] when triggered

Context:

no reportedlegal issues

no reportedlife stressors

no reportedcurrent medical concerns

no reportedrecent loss(es)

Modifying Factors:

[] psychotropic medication(s) / [] herbal supplements / [] therapeutic groups
[] psychotherapy / [] spiritual coping / [] social support
[] non-pharmacological tx / [] other:

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RISK ASSESSMENT

no report ofsuicidal ideation -

no report ofself-harm urges/behaviors

no report ofhomicidal/violent ideation -

Risk Behaviors:

Date / Behavior
-
-
-

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HISTORY

Legal History:

Date / Status/Charges
-
-
-

-

Family History: No reported changes from last evaluation reported by patient/care providers

Social History: No reported changes from last evaluation reported by patient/care providers

Additional Information: N/A

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MEDICATIONS

Allergies: NKDA

Current Medications:

[] Acetaminophen 650mg PO q6 hours PRN - general pain
[] Alamag Plus 20mL PO q6hours PRN - dyspepsia
[] Milk of Magnesia 30mL PO QHS PRN - constipation
[] Nicotine Replacement Therapy:
[]
[]
[]
[]

Medication adherence: N/A

Overall efficacy of current psychotropic regimen: N/A

Medication changes:

N/A

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MEDICAL

Medical Concerns: No new complaints reported by patient/care providers

Wellness:No specific health promotion behaviors reported by patient/care providers

Labs/Tests: No new results reported; Ongoing Monitoring: N/A

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MENTAL STATUS EXAM

Vital Signs (3/6): BP - N/A HR - N/A RR - N/A Temp - N/A Height – X Weight – Xlbs

Appearance: ASA , appropriate attire, well-groomed, appropriate hygiene, averagebuild, average height

Attitudes and Behavior:calm, pleasant, cooperative, appropriate eye contact, abnormal gestures/mannerisms not observed

Muscle tone and Strength: appears WNL, not formally tested

Gait and Station: steady gait, erect posture

Mood: “x”

Affect:euthymic, full, even,congruent with stated mood, appropriate to situation

Speech: spontaneous,normal rate, appropriate volume/tone, fluent

Language: no problems expressing self, able to comprehend questions

Ideation:no voiced delusions, no voiced bizarre content, no voiced suspiciousness

Perception:no voiced AH, no voiced VH,no voiced command hallucinations

Thought Process:linear, coherent, goal-directed

Thought Content:no abnormal content elicited,no voiced paranoia

Suicide Assessment:denies current ideation

Homicide/Violent Ideation:denies current ideation

Impulsivity:lowrisk, considering current presentation and past history

Sensorium and Cognition

Level of Consciousness:alert

Patient Orientation:fully oriented

Ability to Recall:normal

Memory Description:recent events:intact,remote events: intact

Attention/Concentration:appropriate, ableto recall details of prior meeting

Abstract Thinking:intact, not formally tested

Fund of Knowledge:average

Estimated Intelligence:average, vocabulary fluent

Reliability: appears adequate

Judgment:fair

Insight:fair

Additional Findings:

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DIAGNOSIS:

[INSERT HERE]

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DELIVERY OF CARE

Medical Decision Making

[] Minor Problem: -

[] Established Problem: -

[] New problem: -

Patient/Family counseled on:

[] prognosis / [] risk/benefit of treatment / [] risk factor education
[] psychoeducation: / [] other:

[] Reviewed chart: (findings noted above)

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ASSESSMENT(Required):

[XX]-year-old [employment status]Caucasian[marital status][gender] with current diagnosis of [diagnoses], admitted to WRCH from [Facility] on [Admission Date] under Section 16b for commitment for treatment due to expire on [Expiration Date] on charges of [charges] was referred for symptoms/behaviors.

According to patient: patient denies mood symptoms, denies anxiety issues,denies psychotic symptoms, including delusional beliefs and perceptual disturbances.

Patient appears to be stable and appears to havecontrol of behavior. Patient likely poses a minimal risk to self and a minimalrisk to others at this time.

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PLAN (Required):

Action Plan:

  1. ContinueObservation status: 30 minfor safety
  2. No changes to current diagnoses at this time
  3. No changes to current medications at this time
  4. Risks vs. benefits of ongoing treatment with psychoactive medications were assessed and benefits outweigh risks. Discussed appropriate Black Box Warnings, possible alternatives, including non-pharmacological approaches.

Psychopharmacology Treatment Plan:

-Continue to diagnostically assess and adjust medications as needed

-Attain and maintain symptom remission

-Monitor efficacy, tolerance and adverse effects of medications

-Perform appropriate diagnostic testing as needed

-Collaborate with other care providers/organizations to ensure continuity of treatment as appropriate