Chief Complaint : Reason for seeking health. Includes a direct quote from patient about presenting
Demographics : Begins with patient initials, age, race, ethnicity, and gender (5 demographics).
History of the
(HPI) – Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors,Timing, and Severity).
Allergies – Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy).
Systems (ROS) – Includes a minimum of 3 assessments for each body system, assesses at least 9 body systems directed to chief complaint, AND uses the words “admits” and “denies.”
Vital Signs – Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain).
Labs, Diagnostic, PERFORMED. During the visit:
Includes a list of the labs, diagnostic or screening tools reviewed at the visit, values of lab results or screening tools, and highlights abnormal values, OR acknowledges no labs/diagnostic were reviewed.
Medications- Includes a list of all of the patient reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency).
(Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the
diagnosis is active orcurrent.
History- Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including ADDICTION treatment and date of the diagnosis)
History- Includes an assessment of at least 6 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts.
Social History- Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive
use/pregnancy status, and living situation.
– Includes all 10 components of the mental status section (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/perception, cognition, insight and judgement) with
detailed descriptions for each area.
Diagnoses- Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)using the DSM-5-TR. The correct ICD-10
billing code is used. DSM-5-TR. The correct ICD-10 billing code is used.
Diagnoses: Includes at least 2 differential diagnoses that can be supported by the subjective and objective data provided using the DSM-5-TR. The correct ICD-10 billing code is used.
Tools – After the visit: orders
or screening tool
100% of the time OR
clinically required at
Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent.
For non- pharmacological treatment, includes: treatment name, frequency, duration. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is
supported by the cufrent US guidelines.
Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives.
Referral : Provides a detailedlist of medical and interdisciplinary referrals or NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments.
APA Formatting : Effectively uses literature and other resource. Exceptional use of
citations and extended referencing. High level of precision with APA 7th Edition writing style.
References: The references contains at least the required current scholarly academic reference and in-literature citations reference. Follows APA guidelines of components: double space, 12 pt. font, abstract, level headings, hanging indent.
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