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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.
Homicidal:
Past Suicide:
Passive Thoughts
Active Recurrent Thoughts
Making Threats
Actionable Plans
Available Means
Currently Attempted
Attempts in family history
If parent, please indicate
Was the parent‘s attempt
successful?
Consumer denies current thoughts of other-directed harm at this time.
Passive Thoughts
Active Recurrent
Thoughts
Making Threats
Actionable Plans
Available Means
Hx of violence
Hx of family
violence
NA
Thoughts
Plans
Attempts
Thoughts
Plans
Attempts
If yes, how many
attempts?
Past Aggression:
NA
If yes, how many
attempts?
OTHER FACTORS:
Lack of Support
Recent Loss
Unstable Living
Arrangement
Medical/Health Risks
Fear of Losing Control
Fear of Being Controlled
Current Substance
Abuse
Command
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:
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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:
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PSYCHIATRIC EVALUATION / PLAN
SUBSTANCE USE ASSESSMENT
Current Substance Use Patterns:
Prior Substance Use Treatment for Individual / Family:
Drug
Method
Age 1st
used
Age
last
used
Onset of
heavy
use
Amt.
used in
past 48
hrs.
# days
used in
last 30
1st as
RX?
Last
used
when?
Amt. used
daily/weekly
Drug of
choice?
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?
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
No
Yes
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:
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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:
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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:
Name of Covered Support or Service Needed
(Scope)
Amount/
Intensity
(Units)
Psychiatric Evaluation (Assessment & Evaluation)
One visit
By When
(Duration)
By Whom
(Who will assist with this goal?)
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
Name of Covered Support or Service Needed
(Scope)
Medication Review
Amount/
Intensity
(Units)
Visits q __
weeks/mths
By When
(Duration)
By Whom
(Who will assist with this goal?)
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:
Address Here
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PSYCHIATRIC EVALUATION / PLAN
Notes:
None
SIGNATURES:
Nurse Practitioner/Nurse Signature
NP / RN
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: