Psychiatric Progress Notes Guidelines

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Questions and Answers

Match the following psychiatric progress notes elements with their definitions:

Subjective = Documentation based on the patient's personal views or feelings Chief Complaint = The first statement reported by the patient History of Present Illness = A detailed narrative describing the patient's symptoms and clinical picture Objective = Documentation of measurable data and test results

Match the following psychiatric progress notes elements with their purposes:

Chief Complaint = To identify the patient's main reason for the appointment History of Present Illness = To provide a detailed narrative of the patient's symptoms and clinical picture Assessment = To identify the patient's diagnosis or problem list Plan = To outline the patient's treatment and management strategy

Match the following psychiatric progress notes elements with their components:

Subjective = Patient's personal views or feelings, and information from others Objective = Vital signs, physical examination, and laboratory results Assessment = Diagnosis, problem list, and relevance to the patient's condition Plan = Treatment, interventions, and follow-up appointments

Match the following psychiatric progress notes elements with their example content:

Chief Complaint = Patient states 'I feel overwhelmed by constant worry and fear, and I'm having frequent panic attacks.' History of Present Illness = Roberta is a 48 y/o Hispanic female, presents for a follow-up appointment to address persistent symptoms of anxiety and panic attacks. Assessment = Axis I: Major Depressive Disorder, Axis II: None, Axis III: Hypertension Plan = Prescribe Fluoxetine 20mg daily, follow-up appointment in 2 weeks Signup and view all the answers

Match the following psychiatric progress notes guidelines with their purposes:

SOAP = To organize and structure psychiatric progress notes HIPAA = To ensure confidentiality and security of patient information Axis = To classify psychiatric diagnoses and disorders ICD-10 = To code and classify diseases and health problems Signup and view all the answers

Match the following patient history sections with their descriptions:

Medical history = Relevant current or past medical conditions diagnosed by a qualified healthcare professional. Surgical history = Including the year of the surgery and surgeon if possible. Family history = Including pertinent family medical history. Social history = Using the HEADSS acronym: Home, Education, Employment, Eating, Activities, Drugs, Sexuality, and Suicide/Depression. Signup and view all the answers

Match the following patient assessment components with their descriptions:

Vital Signs = Including weight, height, blood pressure, glucose level, and/or heart rate. Mental Status Exam (MSE) = The observable status of the patient. Objective notes = An unbiased and factual account of the patient's presentation. Current Medications = Including medication name, dose, route, and frequency. Signup and view all the answers

Match the following patient symptoms with their corresponding psychological responses:

Rapid heartbeat = Fear and anxiety Shortness of breath = Panic and apprehension Trembling = Anxiety and loss of control Sweating = Intense fear and panic attacks Signup and view all the answers

Match the following patient concerns with their corresponding treatment goals:

Worries about losing control = Reducing anxiety symptoms. Feeling constantly on edge = Improving daily functioning. Fear of panic attacks in public = Increasing self-confidence. Desire for relief from anxiety = Enhancing quality of life. Signup and view all the answers

Match the following patient assessments with their corresponding information:

Appearance = Patient's physical appearance and grooming. Behavior = Patient's observable behavior and demeanor. Mental Status Exam = Patient's cognitive and emotional state. Vital Signs = Patient's physiological measurements. Signup and view all the answers

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Study Notes

Psychiatric Progress Notes Guidelines

Outline for Initial Psychiatric Evaluation

Follows SOAP guidelines: Subjective, Objective, Assessment, and Plan
Initial psychiatric evaluation for medication management progress notes

Subjective

Documentation based on patient's or someone close to them personal views or feelings
Chief Complaint (CC): presenting problem reported by the patient
CC can be a symptom, condition, previous diagnosis, or a short statement describing why the patient is presenting today
Multiple CCs are possible, and the first complaint may not be the most significant one
Briefly summarize the patient's main reason for the follow-up appointment
CC can only be deduced after the patient states all their problems

History of Present Illness (HPI)

Provides a detailed narrative describing the onset, duration, severity, and progression of current symptoms
Context for the patient's chief complaint, including relevant psychosocial factors, symptoms, triggers, or exacerbating factors
Includes patient's name, age, gender, and relevant demographic information

History

Medical history: Relevant current or past medical conditions based on a thorough assessment by a qualified healthcare professional
Surgical history: Include year of surgery and surgeon if possible
Family history: Pertinent family history
Social History: Use HEADSS acronym to document Home and Environment; Education, Employment, Eating; Activities; Drugs; Sexuality; and Suicide/Depression
Current Medications, Allergies: Include medication name, dose, route, and frequency

Objective

Unbiased and factual account of the patient's presentation, informing the assessment and treatment plan
Vital Signs: Weight, Height, blood pressure readings, glucose level, and/or heart rate if present
Mental Status Exam (MSE): Observable status of the patient, including appearance and behavior