PHYSICIAN PROGRESS NOTE / Comprehensive Progress Note
Date: _____________
Start Time: ______ AM / PM
Length of session: _____________
End Time: ______ AM / PM
Location: _____________
NURSING/CM ASSESSMENT
Client Name: __________________________
Medical Record #: _________
Physician: _________________________
Procedure:  Med Man (5900)
 Med Eval (6100)
 Annual Psy Eval (0451)
Current Diagnosis: ______________________________________________________
Current Algorithm:  MDD-NP  MDD-P  BD  MANIA  DEP  SCZ  NONE
Alg. Stage __________________
Weeks in this stage ____________________
VITAL SIGNS: BP ______________
Pulse______________
Temp _____________
Height ___________ Weight ___________
List regular medications: (prescription, OTC, herbals, please specify)
____________________________________________________________________________
____________________________________________________________________________
Has client taken meds as prescribed (per client report)
 YES (mostly)  NO (inadequate)
Since the last visit have there been any hospitalizations, surgery/procedures or lab work?
____________________________________________________________________________
Drug levels: Y / N
Medication _______________ Date Drawn _________
Serum Level _________ Lab results: Normal __________ Abnormal ___________
SUBSTANCE USE HISTORY PRESENT /PAST: List Substances (score severity 0-10)
Type
Last Use
Severity
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
Discus Exam last done on _____________
Score ______________
N/A ___________
Client Global Self Report (0 – 10 scale, 0 no symptoms, 5 moderate, 10 severe)
Symptoms ____________
Side Effects ____________
CLINICAL RATING SCALES
POS SX: ____ NEG SX: ____ DIDS-SR: ____ QIDS_C: ____ BDSS: ____ OTHER: ____
Nurse Signature: _____________________________________________________
PHYSICIAN ASSESSMENT
Time In____Time Out____--Length of session_____ Procedure code______Location__________
Core Symptoms:  Mania  Depression  Positive Symptoms or Psychosis  Negative Symptoms
Other Symptoms:
 Irritability Mood Lability  Agitation  Anxiety  Apathy  Insomnia
Energy Level ↑↓ _____ Appetite ↑↓ _____ Level of Interest ↑↓ _____
 Sexual Dysfunction other (specify) __________________________
Is Client suicidal? YES / NO (specify in narrative progress note, including action taken).
Is Client homicidal? YES / NO (specify in narrative progress note, including action taken).
SUBJECTIVE FINDINGS
Appetite:
 Normal  Poor  Good  Overeating  Fair
Sleep:
 Normal  Poor  Good  Fair
Medication Efficacy:
 Excellent  Good  Fair  Poor  Minimal
Medication Adherence:
 Excellent  Good  Fair  Poor  Minimal
Comments: _____________________________________________________________________
____________________________________________________________________________
Side Effects
 None
 Tremors
 Akathesia
 Involuntary Movements
 GI
 Sexual
 Appetite
 Sedation
 Other______________
Physician Report (0 – 10 scale, 0 no symptoms, 5 moderate, 10 severe)
Symptom severity: ___________
Side effect Severity: ___________
OBJECTIVE FINDINGS
Orientation:
 Person  Place  Time  Situation
Rapport:
 Appropriate  Hostile  Evasive  Distant  Inattentive
 Poor Eye Contact
Appearance:
 Appropriately Dressed  Appropriately Groomed  Body Odor
 Poorly Dressed  Poorly Groomed  Disheveled
Mood:
 Euthymic  Depressed  Anxious  Angry  Irritable  Elated
Affect:
 Appropriate  Depressed  Expansive  Blunted  Flat  Labile
Speech:
 Coherent  Appropriate  Incoherent  Loose Associations
 Circumstantial  Tangential  Poverty
Thought Content/Process:  Appropriate  Goal-Directed  Delusional  Persecution
 Reference  Thought Insertion  Broadcasting  Grandiose
 Obsessions  Compulsions  Phobias  Suicidal Ideation
 Suicidal Plan  Homicidal Ideation  Homicidal Plan
 Hopelessness  Worthlessness  Loneliness  Guilt
 Self Depreciation  Hallucinations (Describe:  Auditory  Visual
 Command)
Insight:
 Excellent  Good  Fair  Poor  Grossly Impaired
Judgment:
 Excellent  Good  Fair  Poor  Grossly Impaired
Cognitive:
 No Gross Cognitive Deficits  Concentration Problems
 Concrete  Abstract  Easily Distracted
Psychomotor Activity:
 Normal  Restless  Retardation
MemoryImmediate:
 Good  Fair  Impaired
Recent:
 Good  Fair  Impaired
Past:
 Good  Fair  Impaired
Comments:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Any new physical problems? (pain, sleep, sexual ) ___________________________________
_______________________________________________________________________________
LMP:______ Pregnancy: __________________________________________________________
ASSESSEMENT
DIAGNOSTIC IMPRESSION: Psychiatric (DSM-IV):
Axis I:
__________________________________________________________________
Axis II:
__________________________________________________________________
Axis III:
__________________________________________________________________
Axis IV:
__________________________________________________________________
Axis V:
GAF (0 -100) = _____________________
PLAN:
Continue current meds? YES / NO
If no, change meds as follows:
_______________________________________________________________________________
_______________________________________________________________________________
If, meds are being changed, rationale for change:
 Insufficient improvement  Client preference  Side effects intolerable  Symptoms
worsening  Diagnosis change  Critical decision point indicates change is necessary  Other
Risks and benefits of meds were discussed with client? YES / NO
If no, give reason:
______________________________________________________________________________
Client consented to taking medication: YES / NO
If no, give reason:
______________________________________________________________________________
Is Client capable of administering own meds? YES / NO
If not, who will administer?
_____________________________________________________________________________
Labs ordered? YES / NO
If yes, please see lab order form.
______________________________________________________________________________
SUMMARY ( Additional information only if indicated)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Progress Note: check here if note was dictated ________. Date of Dictation ______________.
Schedule follow-up in ____________ weeks. _________ month(s)
SIGNATURE _____________________________________
Date: ___________________