Psychiatric Progress Note – Fill Out and Use This PDF

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.

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)