Psychiatric Evaluation Form - DOC by Xy5ibUm0

VIEWS: 221 PAGES: 6

									Logo Here              Address Here

                                                                      PSYCHIATRIC EVALUATION / PLAN

Procedure Code:       90801         Service Date:                               Start Time:                  Stop Time:

Chief Complaint (Individual’s words regarding why he or she is being seen):

RISK ASSESSMENT

CURRENT STATUS: Check all that apply. BOLD, highlighted items are highly significant for hospitalization.

     Suicidal:                      Consumer denies current thoughts of self harm and is future-oriented.

                                    Passive Thoughts                       Active Recurrent Thoughts               Making Threats

                                    Actionable Plans                       Available Means                         Currently Attempted
                                                                                                                   Was the parent‘s attempt
                                    Attempts in family history             If parent, please indicate
                                                                                                                   successful?
     Homicidal:                     Consumer denies current thoughts of other-directed harm at this time.
                                                              Active Recurrent
                                    Passive Thoughts                                           Making Threats
                                                              Thoughts
                                                                                                                              Hx of family
                                    Actionable Plans          Available Means                  Hx of violence
                                                                                                                              violence
     Past Suicide:                  NA                        Thoughts                         Plans                          Attempts
                                         If yes, how many
                                             attempts?
     Past Aggression:               NA                        Thoughts                         Plans                          Attempts
                                         If yes, how many
                                             attempts?

OTHER FACTORS:
                                                                                    Unstable Living                      Current Substance
         Lack of Support                        Recent Loss
                                                                                    Arrangement                          Abuse
                                                                                                                         Command
         Medical/Health Risks                   Fear of Losing Control              Fear of Being Controlled
                                                                                                                         Hallucinations
         Marked or Severe ADLs

DANGEROUSNESS

         Self                                          Others                       Inability to Care for Self

         Inability to recognize need for TX

RISK ACTION STEPS FOR STAFF:
               Intensity of
         service/contacts to:
                Level of Care to:


         Risk Assessment daily for:                   Days       Monitor for:                             Report to:

         Risk Assessment weekly for:                  Weeks Monitor for:                                  Report to:


         Client Name:
                 DOB:                                                                                                                Section 8
          Staff Name:                                                                                            Last revised: January 15, 2009
       Case Number:                                                                                                                 Page 1 of 6
    Medicaid Number:
Logo Here              Address Here

                                                                 PSYCHIATRIC EVALUATION / PLAN

         Risk Assessment monthly for:              Months Monitor for:                              Report to:

Other Action Step(s):

History of Present Illness:

Allergies:

Current Medications (psychotropic, medical, herbal, over-the-counter):

History of Adjustment to previous medications:

PRN Medications (name and how administered):               for the symptoms of

Case referred to BMRC, date for initial BMRC review:

Medical History: (check one) (sleep history (include sleep apnea), appetite, weight loss, past surgeries, past medications and
response, hypertension, diabetes, seizures, liver disease)

       See valid data from current Psychosocial Assessment            Date completed:

       Updated information:

Psychiatric History: (check one)

       See valid data from current Psychosocial Assessment             Date completed:

       Updated information:

Family / Social / Sexual History:

       See valid data from current Psychosocial Assessment             Date completed:

       Updated information:


FORMAL MENTAL STATUS EXAM

  Attitude and Behavior: (attitude toward interviewer; contact with environment; dress; expressive movements; facial expression;
  motor activity)

  Stream of Mental Activity: (verbal productivity; spontaneity; distractibility; language deviations; reaction time)

  Emotional Reactions: (emotional display; predominant affect; persistence of mood; variability of affect; appropriateness of affect)


  Mental Trend: (persecutory ideas; suspiciousness; hypochondria; ideas of unreality; nihilism; depressive trends; grandiosity;
  hallucinations; illusions; delusions; phobias; obsessions; preoccupations; suicidal ideation; homicidal ideation)

  Sensorium, Mental Grasp and Capacity: (orientation; memory – recent, remote, immediate; retention and recall; calculation;
  school – general knowledge; intelligence)

  Insight and Judgment: (awareness of defects; personal judgment; impersonal judgment; plans for the future)



         Client Name:
                  DOB:                                                                                                       Section 8
             Staff Name:                                                                                 Last revised: January 15, 2009
        Case Number:                                                                                                        Page 2 of 6
    Medicaid Number:
Logo Here              Address Here

                                                               PSYCHIATRIC EVALUATION / PLAN

SUBSTANCE USE ASSESSMENT

Current Substance Use Patterns:

Prior Substance Use Treatment for Individual / Family:

                                                                                   Amt.
                                             st   Age     Onset of    # days                   st    Last
                                       Age 1                                      used in   1 as               Amt. used       Drug of
       Drug                Method                  last    heavy      used in                        used
                                        used                                      past 48    RX?              daily/weekly     choice?
                                                  used      use       last 30                       when?
                                                                                   hrs.




Comments:

Any changes in patterns of use over time?
Does individual ever drink or drug more than he/she intends?               No         Yes
Has individual experienced an increase in the amount he/she can use to get the same effect?              No          Yes
Is there a history of overdose?         No           Yes, describe:
Is there a history of seizures?         No           Yes, describe:
Is there a history of blackouts?        No           Yes, describe:
Has individual ever used medications to either get high or come down from being high?               No         Yes
With whom does individual usually use?
Has individual had previous substance abuse treatment?                No         Yes, where:
Diagnostic Impressions for this section:


DSM – IV DIAGNOSIS (Codes must be specific up to the 5th digit if necessary. Indicate principal diagnosis with a ‘P’)
                                                                                Changes
                    Code

                    Code
Axis I:
                    Code

                    Code

                    Code
Axis II:
                    Code

                    Code
Axis III:           Code

                    Code
Axis IV:         Check all that are appropriate below and specify the problem:


            Client Name:
                  DOB:                                                                                                     Section 8
             Staff Name:                                                                             Last revised: January 15, 2009
           Case Number:                                                                                                 Page 3 of 6
    Medicaid Number:
Logo Here                Address Here

                                                                     PSYCHIATRIC EVALUATION / PLAN

        Problems with primary support group (e.g. losses or disruptions in family or other natural supports, abuse, neglect, changes in
        family group)
        Specify:

        Problems related to the social environment (e.g. losses and disruptions in friendships, inadequate supports, lack of leisure
        opportunities, life cycle transition problems)
        Specify:

        Educational problems (e.g. inadequate environment, inadequate education, illiteracy, problems at school)
        Specify:

        Occupational problems (e.g. unemployment, threat of job loss, conflict/stress in workplace, lack of employment skills)
        Specify:

        Housing problems (e.g. homelessness, inadequate housing, unsafe neighborhood, conflict in neighborhood)
        Specify:

        Economic problems (e.g. poverty, lack of entitlements, lack of supports and resources; lack of clothing)
        Specify:

        Problems with access to health care services (e.g. little or no insurance, transportation problems, inadequate available services)
        Specify:

        Problems related to interaction with the legal system / crime (e.g. arrest, incarceration, litigation, victimization, probation/parole)
        Specify:

        Other psychosocial & environmental problems (e.g. disasters, conflict with service providers, lack of social service agencies)
        Specify:

        None
        Specify:

    Axis V:

TREATMENT PLAN

A. Target Symptoms/Behaviors/Concerns: (Include health/medical issues, e.g., hypertension, diabetes, etc; substance abuse;
   safety issues)

    
    
    
    
    
    


B. Goals, Interventions and Objectives: (must address target behaviors/symptoms and include medications, recommended
            Client Name:
                   DOB:                                                                                                             Section 8
             Staff Name:                                                                                       Last revised: January 15, 2009
          Case Number:                                                                                                             Page 4 of 6
    Medicaid Number:
Logo Here             Address Here

                                                                 PSYCHIATRIC EVALUATION / PLAN

   evaluations, follow-up and communication with primary care physician, health and safety issues and substance abuse issues)

  Goal/Dream (state goal in collaboration with client):

  State desired result(s) in client’s words:

                                                             Amount/
  Name of Covered Support or Service Needed                                      By When                            By Whom
                                                             Intensity
                   (Scope)                                                       (Duration)              (Who will assist with this goal?)
                                                               (Units)

 Psychiatric Evaluation (Assessment & Evaluation)             One visit
  Objectives of this Service or Support with Target Dates:

    
    
    

  Interventions:

        Investigate clinical status, mental status, relevant history, personal strengths and assets.
        Establish plan of care for medication management.
    
    
    


Notes:        None


                                                             Amount/
  Name of Covered Support or Service Needed                                     By When                            By Whom
                                                             Intensity
                   (Scope)                                                      (Duration)              (Who will assist with this goal?)
                                                               (Units)
                                                            Visits q __
                 Medication Review                          weeks/mths
  Objectives of this Service or Support with Target Dates:

    
    
    

  Interventions:

     Evaluate and monitor effectiveness of medications
     Evaluate and monitor side effects
     Evaluate and monitor need for continued medication/change in medication
    
    



          Client Name:
                 DOB:                                                                                                              Section 8
           Staff Name:                                                                                        Last revised: January 15, 2009
         Case Number:                                                                                                            Page 5 of 6
    Medicaid Number:
Logo Here             Address Here

                                                      PSYCHIATRIC EVALUATION / PLAN

Notes:        None

SIGNATURES:



                                                                NP / RN
   Nurse Practitioner/Nurse Signature                           Credentials     Date



   Physician (Psychiatrist) Signature (if required)             Credentials     Date




          Client Name:
                DOB:                                                                              Section 8
           Staff Name:                                                        Last revised: January 15, 2009
         Case Number:                                                                            Page 6 of 6
    Medicaid Number:

								
To top