Psychiatric Progress Note PDF Details

The psychiatric progress note form can be a vital tool in tracking the mental health of a patient. It can help to provide a bird's eye view of the patient's condition, as well as track any changes or improvements over time. This form can also be used to communicate with other medical professionals about the patient's care. The psychiatric progress note form usually includes sections for demographics, chief complaint, history of present illness, past medical history, social history, family history, review of systems, medication and allergies, physical examination findings, diagnostic impressions, and treatment plan. As you can see, there is a lot of information that can be captured on this form.

Here is the data relating to the PDF you were in search of to fill out. It can show you the time you'll need to complete psychiatric progress note, exactly what parts you will need to fill in, and so on.

QuestionAnswer
Form NamePsychiatric Progress Note
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namespsychiatric note template, outpatient psychiatry note template, psychiatry template, psychiatric progress note template

Form Preview Example

M S D P S T A N D A R D I Z E D D O C U M E N T A T I O N T R A I N I N G M A N U A L

Psychiatry/Medication Progress Note

This note is to be completed ONLY by a psychiatrist or advanced practice nurse with prescribing privileges for a psychopharmacology service.

Data Field

 

 

Identifying Information Instructions

 

Person’s Name

 

 

Record the first name, last name, and middle initial of the person being served. Order of

 

 

 

name is at agency discretion.

 

 

 

 

 

 

 

 

 

 

Record Number

 

 

Record your agency’s established identification number for the person.

 

 

 

 

 

 

 

 

 

 

Date of Admission

 

 

Record the date of admission per agency policy (this should be the first service date for

 

 

 

this service episode).

 

 

 

 

 

 

 

 

 

 

Organization/Program

 

 

Record the organization and Program for whom you are delivering the service.

 

Name

 

 

 

 

 

 

 

 

 

DOB

 

 

Record the person’s date of birth

 

 

 

 

 

 

 

 

 

 

Gender

 

 

Indicate person’s gender by checking the appropriate box. If checking “Transgender” box,

 

 

 

also complete box of current gender designation for insurance purposes.

 

 

 

 

 

 

 

 

 

 

List of Names of Persons

 

 

Check appropriate box: Person Present; No Show; Person Canceled. If Provider

 

Present

 

 

Canceled is checked, document explanation as relevant.

 

 

 

If Others Present is checked, identify name(s) and relationship(s) to person.

 

 

 

 

 

 

 

 

 

 

Interim History

 

 

Document an interval history of client including progress made since last session,

 

 

 

 

effectiveness of medications, progress related to symptoms, substance use, significant

 

 

 

 

new issues, changes in family and social history and overall functioning.

 

 

 

 

 

 

Mental Status

 

 

Comment on current areas of mental status evaluation, including significant changes

 

 

 

 

since last visit. Document any risk issues and if present, document action plan to

 

 

 

 

address.

 

 

 

 

 

 

Takes meds as prescribed

 

 

Record whether medication was taken as prescribed since last session, yes/no or n/a.

 

 

 

 

Provide additional relevant information after Comments.

 

 

 

 

 

 

Side Effects

 

 

Record whether side effects are present or occurred since last session, yes/no or n/a.

 

 

 

 

Provide additional relevant information after Comments, e.g. increased thirst, dizziness,

 

 

 

 

decreased sexual function.

 

 

 

 

 

 

Allergic Reactions

 

 

Record any reported or observed allergic reactions to medications. As appropriate,

 

 

 

 

provide additional relevant information after Comments.

 

 

 

 

 

 

Changes in Medical Status

 

 

Record whether there have been any changes in medical status since last session,

 

 

 

 

yes/no or n/a. Provide additional relevant information after Comments.

 

 

 

 

 

 

Other Meds

 

 

Record any new medications the person has been taking since the last session, e.g. over

 

 

 

 

the counter/herbal/ none/other. Provide additional information after Comments. .

 

 

 

 

 

 

Goal(s) Addressed as Per

 

 

Identify the specific goal(s) and objectives in the Psychopharmacology Action Plan or

 

Psychopharmacology Plan

 

 

Individual Action Plan being addressed during this intervention.

 

 

 

 

 

 

 

 

 

 

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M S D P S T A N D A R D I Z E D D O C U M E N T A T I O N T R A I N I N G M A N U A L

Therapeutic Interventions

 

 

Check one or more of the types of interventions delivered in the session:

Delivered in Session

 

 

Psychotherapy, Counseling/Coaching, Collaborative Medication Management,

 

 

Collaborative Medication Education/Symptom/Illness Management, Injections, Physical

 

 

 

 

 

 

Assessment, Coordination of Care. For additional interventions utilized check other.

 

 

 

Describe the content of the interventions. If any off-label usage or more than one anti-

 

 

 

psychotic is prescribed it is suggested that the decision-making of the prescriber be

 

 

 

carefully documented.

 

 

 

 

Response to Intervention

 

 

Document person’s response to intervention(s) delivered in the session and person’s

Delivered in Session and

 

 

progress towards goals and objectives. If no progress is made over time, this section

 

 

should also address changes in strategy to produce positive change in the person.

Progress Toward Goals

 

 

 

 

 

and Objectives

 

 

 

 

 

 

 

Lab Tests Ordered

 

 

Summarize key laboratory test results received and reviewed. Check appropriate box to

 

 

 

indicate whether key laboratory test results were ordered or, reviewed (with person). If

 

 

 

lab results were not received, describe action to be taken to obtain results.

 

 

 

 

AIMS Findings

 

 

If AIMS (Abnormal Involuntary Movement Scale) test was administered, document

 

 

findings.

 

 

 

 

 

 

 

Height/Weight/BMI

 

 

Record information pertaining to person’s height, weight, body mass index, blood

Blood Pressure/VS

 

 

pressure, and vital signs as relevant. Document if there has been communication

 

 

between the prescriber and the PCP. Provide additional relevant information as

 

 

 

appropriate.

 

 

 

 

Diagnosis

 

 

Document whether the person’s diagnosis has changed or not. If diagnosis has

 

 

 

changed, check yes and proceed to Comprehensive Assessment Update form.

Data Field

 

 

Medication Orders Today

None Prescribed

 

 

Check box if no medications are prescribed today. If so, proceed to Next Appointment

 

 

 

data field.

Rationale for Changes in

 

 

Document rationale for any medication changes. For each medication prescribed,

Medications

 

 

indicate if the medication is renewed(renew) /changed, newly prescribed (new) or

 

 

discontinued (D/C). Write the name of the medication (med), dosage (dose), frequency

 

 

 

 

 

 

(frequency), # of Days, quantity (qty), and number of refills (refills) prescribed.

 

 

 

For each new medication prescribed, the person should be given information about

 

 

 

medication risks and benefits. Check the appropriate box indicating whether person has

 

 

 

given “informed consent”, i.e. demonstrated an understanding of medication’s risks and

 

 

 

benefits. Documentation of “Informed Consent” is mandatory. If the person does not

 

 

 

demonstrate an understanding of the risks and benefits, then the prescriber should

 

 

 

indicate in the Instructions /Comments Section what steps should be taken.

 

 

 

This section should not be a substitute for a complete listing of medications.

 

 

 

 

Instructions/Comments, as

 

 

Document any additional relevant instructions or psycho-educational information.

applicable:

 

 

 

 

 

 

 

Next Appointment

 

 

Document time frame when the person should return to see the prescriber.

 

 

 

 

MD/DO/APN (Print Name)

 

 

Legibly print the MD/DO/APN’s name.

 

 

 

 

MD/DO/APN Signature &

 

 

Legibly record provider’s signature, credentials and date.

Credentials

 

 

 

 

 

 

 

Supervisor - Print

 

 

If required, legibly print name of supervisor, credentials and date.

Name/Credential (If

 

 

 

needed)

 

 

 

 

 

 

 

Supervisor - Signature (If

 

 

If required, legible record Supervisor Signature.

needed)

 

 

 

 

 

 

 

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