Criteria Clinical Notes Subjective Include chief complaint subjective

Criteria clinical notes subjective include chief

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Criteria Clinical Notes Subjective
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Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History. Objective
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This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Include MSE, risk assessment here, and psychiatric screening measure results. Assessment
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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. Plan
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Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment. CG&AM&BF_10/10/18 Week 4 Discussion 1: Psychosis Case Study
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Follow the steps to complete this discussion: 1. Watch the Video 2. Using the readings and references, write a treatment note for this patient following the Psychiatric SOAP Note Template (Word) . Include a prescriptive decision in your case. What medication would you choose? Why? If you do not choose to medicate, why? What is your starting dose? How would you decide to titrate dose, if appropriate? What labs would be required? When? This is your opportunity to practice prescribing and it is important that you give it a try and then discuss those decisions and compare with your peers. 3. Organize your SOAP Note as follows: · Subjective: Reported assessment data. Patient’s Psychiatric and Medical History, and Patient’s Family Psychiatric History. · Objective: Observed assessment data (include MSE and lab findings). · Assessment: Diagnostic impression. Identification of target symptoms. Your thoughts about the case and an explanation of your proposed decision making.
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· Plan: Your plan of care. Include prescriptive decisions, laboratory monitoring and recommended screenings and non pharmacologic interventions like psychotherapy. 4. Submit your treatment plan (P of SOAP note) to this discussion forum by Day 5. 5. Submit your complete Psychiatric SOAP note for grading to the Week 4 Assignment: Psychosis Case Study. 6. Consider the points on the grading rubric when writing your note.
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