Client discussed focus of treatment with new therapist, to include creating a safety plan, using supports and accessing various activities to reduce isolation, depressive symptoms and substance use. Client reported medication compliance 95% of the time.
Client reports recent stressors with upcoming holidays and feeling lonely as family lives far away . Discussed potential to increase meds, however client reports that he is able to manage extra stress with help of therapy and breathing exercises. Will keep meds at same dose and monitor for any worsening of symptoms over holidays.
Client was educated on need to remain compliant with medication as prescribed and was given overview of risks of noncompliance. Provider reviewed potential sideeffects of medication.
The sample progress notes below meet criteria for the specified E/M code, but do not necessarily meet criteria for the multiple other purposes (e.g., clinical, legal) of documentation. For illustration, the documentation meets requirements specified by the codes for the exact levels of each of the 3 key components.
Patient Consent /Instructions : The risks, benefits, and side effects of the medication along with reasonable alternative treatments were discussed with _____ (or parent/guardian) and he/she verbalized an understanding and expressed a desire to continue the medication as outlined as the benefits outweigh the risks.
Fill out what goals you are working on, what the target is for those goals, the date the goal was set, and notes on the goal. Fill out the blue highlighted boxes on the first table by copying and pasting your choices from the second table. Fill out the third table immediately after the encounter, with the exception of the time spent in follow-up.
Medication Management with Psychotherapy Progress Note Client Name: Date of Service: Length of Session: ... ☐ Instruction for management/treatment and/or follow-up ☐ Patient/family/caregiver education ... Provider Signature & Credentials (if signature illegible, include printed name): Date of Signature: Title: Medication Management and ...
Document an interval history of client including progress made since last session, effectiveness of medications, progress related to symptoms, substance use, significant new issues, changes in family and social history and overall functioning. Comment on current areas of mental status evaluation, including significant changes since last visit.
Client reported medication compliance 100% of the time. Client was educated on need to remain compliant with medication as prescribed and was given overview of risks of noncompliance.
This document provides a sample process for developing a complete and accurate medication list. Every primary care practice is different, varying by practice size, staffing levels, procedures,