Session Info

Date:

CPT / E&M code:

Session duration (min):

Modality (in-person / telehealth / phone):

Attendance (client / parent / collateral / interpreter):

Consent acknowledged:

History

Chief Concern and HPI

Chief concern:

History of present illness:

Functional impairment:

Psychiatric History

Prior diagnoses:

Hospitalizations / higher LOC:

Prior medication trials:

Psychotherapy history:

Medical and Family History

Medical history:

Family psychiatric history:

Allergies:

Reproductive / pregnancy considerations:

Substance Use

Alcohol:

Cannabis:

Other substances:

Treatment history / withdrawal risk:

Social History

Living situation:

Work / school:

Supports:

Legal / trauma considerations:

Mental Status Exam

Appearance:

Behavior / cooperation:

Speech:

Mood:

Affect:

Thought process:

Thought content (SI / HI / paranoia / AH / VH):

Perception:

Cognition / orientation:

Insight:

Judgment:

Suicidal ideation (current / past / none; plan or intent if present):

Homicidal ideation (current / past / none):

Cognitive screen (MoCA / MMSE / orientation x3 result):

Safety

Immediate safety concerns, protective factors, access to means, and need for collateral or higher level of care reviewed.

Formulation

DSM-5-TR Dx, differential Dx, biopsychosocial formulation, risk formulation, medication/therapy plan, labs, referrals, and CPT support.

Risk/Safety Review

Complete the embedded C-SSRS when suicidal ideation, self-harm, acute risk, or unclear safety status is present; use SAFE-T for full triage when needed.

Assessment Status: Not assessed

Display: Working diagnosis / clinical impression

Block Type: medication-list
Block ID: 68790053-3dc6-4bdb-9541-e1d1ed9eb899
Schema Version: 1

Medications: Item 1

0/27 Score

0 of 9 Answered

minimal 0-4 minimal · 5-9 mild · 10-14 moderate · 15-19 mod-severe · 20-27 severe

Little Interest or Pleasure in Doing Things

0123

Unanswered

Feeling Down, Depressed, or Hopeless

0123

Unanswered

Trouble Falling/Staying Asleep, or Sleeping Too Much

0123

Unanswered

Feeling Tired or Having Little Energy

0123

Unanswered

Poor Appetite or Overeating

0123

Unanswered

Feeling Bad About Yourself — or That You Are a Failure

0123

Unanswered

Trouble Concentrating on Things

0123

Unanswered

Moving or Speaking Slowly, or Restless/Fidgety

0123

Unanswered

Thoughts of Being Better off Dead or Hurting Yourself

0123

Unanswered

Variant: adult
Item Responses

Not Provided/21 Score

Feeling Nervous, Anxious, or on Edge

0123

Unanswered

Not Being Able to Stop or Control Worrying

0123

Unanswered

Worrying Too Much About Different Things

0123

Unanswered

Trouble Relaxing

0123

Unanswered

Being So Restless That It Is Hard to Sit Still

0123

Unanswered

Becoming Easily Annoyed or Irritable

0123

Unanswered

Feeling Afraid as if Something Awful Might Happen

0123

Unanswered

Mood and Attention Differential Screeners

Complete ASRS when attention, executive-function, school/work impairment, stimulant request, or childhood ADHD history is part of the differential.

Status: active
Variant: adult
Responses
Instrument Version: asrs-v1.1-6q

0/6 Score

0 of 6 Answered

Incomplete Four or more shaded-cell responses is a positive screen.

Past 6 months	Never	Rarely	Sometimes	Often	Very Often
1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
2. How often do you have difficulty getting things in order when you have to do a task that requires organization?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?

Complete MDQ before antidepressant or stimulant decisions when elevated or irritable mood, decreased need for sleep, episodic risk-taking, antidepressant activation, or family bipolar history is present.

Status: active
Variant: adult
Symptoms
Instrument Version: mdq-adult-v1

0/13 Score

0 of 13 Answered

Incomplete Requires 7 or more symptoms, same-period yes, and moderate or serious impairment.

You felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?

YesNo

Unanswered

You were so irritable that you shouted at people or started fights or arguments?

YesNo

Unanswered

You felt much more self-confident than usual?

YesNo

Unanswered

You got much less sleep than usual and found that you did not really miss it?

YesNo

Unanswered

You were more talkative or spoke much faster than usual?

YesNo

Unanswered

Thoughts raced through your head or you could not slow your mind down?

YesNo

Unanswered

You were so easily distracted by things around you that you had trouble concentrating or staying on track?

YesNo

Unanswered

You had much more energy than usual?

YesNo

Unanswered

You were much more active or did many more things than usual?

YesNo

Unanswered

You were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?

YesNo

Unanswered

You were much more interested in sex than usual?

YesNo

Unanswered

You did things that were unusual for you or that other people might have thought were excessive, foolish or risky?

YesNo

Unanswered

Spending money got you or your family in trouble?

YesNo

Unanswered

Differential diagnosis:

Biopsychosocial formulation:

Collateral / records reviewed:

Plan and Follow-Up

Focus	Documentation
Assessment	Clinical impression, diagnostic formulation, severity, strengths, barriers, and uncertainty. Clinical impression: Differential / rule-outs: Strengths and barriers:
Initial plan	Planned modality, frequency, measures, referrals, coordination, and patient goals. Treatment focus: Frequency / measures: Referrals / coordination:
Risk / follow-up	Risk status, safety actions when indicated, next appointment, and items to complete before then. Risk status: Follow-up interval: Before next visit:

Focus

Documentation

Assessment

Clinical impression, diagnostic formulation, severity, strengths, barriers, and uncertainty.

Clinical impression:

Differential / rule-outs:

Strengths and barriers:

Initial plan

Planned modality, frequency, measures, referrals, coordination, and patient goals.

Treatment focus:

Frequency / measures:

Referrals / coordination:

Risk / follow-up

Risk status, safety actions when indicated, next appointment, and items to complete before then.

Risk status:

Follow-up interval:

Before next visit:

Session Info

History

Chief Concern and HPI

Psychiatric History

Medical and Family History

Substance Use

Social History

Mental Status Exam

Safety

Formulation

Risk/Safety Review

C-SSRS

Assessment Status

Diagnosis

Diagnosis Snapshot

Specialty Block Unavailable

Stored Payload

Item 1

PHQ-9

Over the past 2 weeks, how often have you been bothered by...

GAD-7

Details

Responses

Mood and Attention Differential Screeners

ASRS v1.1 Screener

Details

MDQ - Mood Disorder Questionnaire

Details

Symptoms

Plan and Follow-Up

Counseling - Initial Psychiatric Evaluation

Preview