Session Info

CPT / E&M code:

Session duration (min):

Modality:

In-person

Telehealth

Phone

Attendance:

Client

Parent / Guardian

Collateral

Interval History

Target symptoms since last visit:

Mood — improved / stable / worsened

Anxiety — improved / stable / worsened

Sleep — improved / stable / worsened

Appetite — improved / stable / worsened

Concentration — improved / stable / worsened

Energy — improved / stable / worsened

Medication adherence:

Adherent

Non-adherent — missed doses

Self-adjusted dose

N/A — not on medication

Substance use since last visit:

None

Reduced

Same

Increased

Interval notes:

Side Effects

Side effects reported:

None reported

Weight gain

Sedation / Fatigue

GI (nausea, diarrhea, constipation)

Sexual dysfunction

Headache

Insomnia

Tremor / Akathisia

Dry mouth

Severity:

Mild — tolerable

Moderate — bothersome

Severe — limiting function

ROS Quick Screen

Constitutional — WNL (no fever, weight change, fatigue)

Sleep disturbance

Appetite / Weight change

Energy change

Sexual dysfunction

GI complaint

Cardiopulmonary symptom

Endocrine concern

ROS notes:

Examination

Blood Pressure

Systolic · mmHg

Diastolic · mmHg

Heart rate · bpm

Anthropometrics

Weight · kg

KG LB

Height · cm

CM FT/IN

Temperature · °C

°C °F

Notes

Abbreviated MSE

Appearance:

Well-groomed

Disheveled

Age-appropriate dress

Behavior:

Cooperative

Guarded

Good eye contact

Mood / Affect:

Euthymic

Depressed

Anxious

Affect congruent / full range

Thought Content:

No SI / HI

Passive SI — safety plan reviewed

Active SI — see risk documentation

Cognition:

Alert and oriented

Thought process linear

Insight/Judgment intact

Risk / Safety Review

1. Ideation Level

0 — None 1 — Wish Dead 2 — Nonspecific Thoughts 3 — With Method 4 — With Intent 5 — With Plan

1. Actual Attempt

Self-Injurious Behavior with Intent to Die

2. Interrupted Attempt

3. Aborted/Self-Interrupted Attempt

4. Preparatory Acts or Behaviors

5. Non-Suicidal Self-Injury (NSSI)

Most Recent Behavior

yyyy-mm-dd

Lethality (0-10)

Clinician Risk Override

No Override

Assessment

Diagnosis Search

Working diagnosis

Coding Details

Status

Select status...

Severity

Select severity...

Onset Date

YYYY-MM-DD

Resolved Date

YYYY-MM-DD

Clinical impression:

Treatment response:

Responding — symptom improvement

Partial response

Non-response — consider change

Remission — stable

Relapse / Worsening

Medications & Orders

Medications Add Medication

New Medication

Drug Name

e.g. Amoxicillin

Drug Code

RxNorm code...

Strength

e.g. 500 mg

Route

Select...

Frequency

Select...

Start Date

YYYY-MM-DD

Stop Date

YYYY-MM-DD

Notes

Notes / instructions...

Allergies:

Medication change:

Continue current regimen

Dose increase

Dose decrease

New medication added

Discontinue medication

Switch medication

New Rx / Refill details:

Labs ordered:

BMP / CMP

Lithium level

Valproate level

Lipid panel

Clozapine ANC

Report details

Panel Kind

Blood

Vendor / Lab

e.g. Lifelabs, Dynacare

Panel Name

e.g. CBC, Lipid Panel

Collection Date

YYYY-MM-DD

Result Date

YYYY-MM-DD

Specimen Type

Search specimen...

Panel Status

Final

Source Document

No source document attached

Tests

Tests List Add test

No tests entered yet. Add a test to capture a value and reference interval.

Plan

Patient education:

Coordination / Referrals:

Follow-up:

Plan and Follow-Up

Plan area	Details
Next visit
Orders & referrals
Patient instructions
Monitoring & safety

Session Info

Interval History

Side Effects

ROS Quick Screen

Examination

Vitals

Abbreviated MSE

Risk / Safety Review

C-SSRS

Suicidal Ideation Severity ⓘ

Suicidal behavior (lifetime; most recent date below)

Risk Details

Assessment

Diagnosis Snapshot

Medications & Orders

Medication List

Lab Result

Plan

Plan and Follow-Up

Counseling - Psychiatric Progress Note

Preview