HPI:
Timing- start, feelings before, how often, time of day
Severity- rate, debilitating, severe, impact life, interfere with work or personal life
Setting- what was going on when it began, new changes or stressors, ever had before
Aggravating/alleviating factors- what makes it worse or better
Associated symptomsDepression screen- endorses depressed mood, sleep, loss of interest, decreased energy, appetite,
concentration, guilt, SI; access to lethal weapons?
Mania screen- period of abnormal elevated, expansive, or irritable mood (1 week), grandiosity,
decreased need for sleep, more talking than usual, flight of ideas, distractibility, increased goal activity,
excessive involvement in activities
Psychosis screen- hallucinations
Anxiety Screen- endorses excessive worry, difficulty controlling worry, irritability, concentration, muscle
tension, sleep, physical symptoms, not related to drugs
Social anxiety screen- endorses worry about scrutiny of others, others think bad of them, social
situations provoke fear and worry, social situations are avoided, fear/anxiety is out of proportions,
lasting over 6 months,
Panic screen- endorses heart, sweating, trembling, SOB, choking, nausea, dizzy, chills/heat, parenthesis,
fear of losing control, fear of dying
PTSD screen- endorses flashbacks, hypervigilance, dreams, distress/exposure, avoidance, anger
outbursts, reckless/destructive behavior, exaggerated startle response, problems with concentration
OCD- recurrent and persistent thoughts, behaviors are aimed at preventing or reducing anxiety or
distress, thoughts are time consuming,
Medications- working, side effects
SleepAppetite and weightMood- stable, instable, manic, depressed, irritable, angry
SuicidalLiving situationRelationships (partner, kids)Legal IssuesWork-
Financial-
Psychiatric History:
Past diagnosesInpatientOutpatientRehabPast suicide attemptsPast medicationsTherapy-
Substance Use:
Tobacco/vapeAlcoholPrescription drugsMarijuanaIllegal drugs-
Medical History:
SurgeriesChronic IllnessesSeizuresCurrent MedsAllergies-
Family History:
PsychMedical-
Plan of Care:
Labs
Utilize services at Red Rock as needed
Provided contact information for crisis hotline
Educated and patient states understanding of medications, compliance, self-care, sleep hygiene
Consumer agreed to plan and will follow-up
Reviewed verbal safety plan
Instructed consumer to call or go to the ER if symptoms get worse or if there is an adverse reaction.
*PMP reviewed*
*cut and paste medications*