Psychiatric Progress Notes Guidelines

10 Questions

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

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

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.

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.

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

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.

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.

Study Notes