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Criteria
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Clinical Notes
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Informed Consent
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Informed
consent given to patient about psychiatric interview process and
psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient
has the ability/capacity to respond and appears to
understand
the risk, benefits, and (Will review additional consent during treatment plan
discussion)
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Subjective
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Verify Patient
Name:
Joshua
Age: 12
Minor: Yes
Accompanied by: Grandmother
Demographics: White
HPI: presents with a history of increased irritability,
angry outbursts, poor sleep, and poor concentration. According to his
grandmother, his behavior has been declining recently with the recent
introduction of the younger sister to the home, with more sources of jealousy
and defiance.
Past Medical and Psychiatric History
Joshua possesses a rich trauma history such as being
neglected during childhood, abused physically, and lacking attachment because
of being taken out of parental care. He was diagnosed with oppositional defiant
disorder (ODD) and ADHD recently. In the academic field, Joshua is about two
years behind in reading and does not like remedial reading but likes the art
class. He does not have suicidal or homicidal ideation. Grandmother states
that she feels overburdened and unequivocal with school involvement because
of her trauma history.
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Verify Patient: Name, Assigned identification number
(e.g., medical record number), Date of birth, Phone number, Social security
number, Address, Photo.
Include demographics, chief complaint,
subjective information from the patient, names and relations of others
present in the interview.
HPI:
Past Medical and Psychiatric History,
Current Medications, Previous Psych Med
trials,
Allergies.
Social History, Family History.
Review of Systems (ROS) – if ROS is
negative, “ROS noncontributory,” or “ROS negative with the exception of…”
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Objective
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Joshua was
well dressed, awake, and oriented. Mood was congruent with an irritable
effect. There were a normal rate and tone of speech. The line of thought was
linear and there was no sign of psychosis. There was loss of attention and
concentration. The judgment and insight were also equitable. None of the
abnormal motor activities. No reported vitals. No current medications.
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This is where the “facts” are located.
Vitals,
**Physical Exam (if performed, will not be performed
every visit in every setting)
Include relevant labs, test results, and
Include MSE, risk assessment here, and psychiatric screening measure results.
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Assessment
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Primary diagnosis:
• Attention-Deficit/Hyperactivity
Disorder, Combined Presentation (F90.2)
Oppositional Defiant Disorder (F91.3) is a
commonly recognized psychiatric disorder.
Other Specified Trauma- and Stressor-Related
Disorder (F43.8).
The symptoms of Joshua can be explained by the
emotional dysregulation as a result of the trauma in combination with ADHD
and environmental stressors. Academic and caregiver stress enhance functional
impairment.
Patient
has the ability/capacity appears to respond to psychiatric
medications/psychotherapy and appears to
understand the need for medications/psychotherapy and
is willing to maintain adherent.
Reviewed potential risks & benefits, Black Box
warnings, and alternatives including declining treatment.
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Include your
findings, diagnosis and differentials (DSM-5 and any other medical diagnosis)
along with ICD-10 codes, treatment options, and patient input
regarding treatment options (if possible), including obstacles to treatment.
Informed Consent
Ability
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Plan
(Note some items
may only be applicable in the inpatient environment)
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Introduce trauma-focused cognitive behavioral
therapy (TF-CBT).
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Refer to psychiatric examination with regard
to possible stimulant/non-stimulant ADHD medication.
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Proposal school evaluation on IEP/504 plan.
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Educate psychoeducation and make referral to
family support services.
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Promote good habits, sleep hygiene and
positive reinforcement.
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4-week follow-up to check on the progress of
symptoms and participation in treatment.
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