Initial Evaluation Template

Finished note

Example — generated by Notat from a sample visit

Reason for visit:
Follow-up for a persistent cough and reduced energy over the past 10 days.

Assessment:
Symptoms are improving. No red flags identified during today's review.

Plan:
Continue supportive care, review worsening symptoms, and follow up if symptoms do not settle as expected.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

Initial Evaluation Template:

Identification: [Patient name, age, and gender]

Chief Complaint: [Patient's chief complaint in quotes]

History of Present Illness:
[Brief summary of patient's history of present illness, including onset, duration, and severity of symptoms]

Psychiatric review of systems:
Depressive symptoms: [Description of patient's depressive symptoms]
Anxiety symptoms: [Description of patient's anxiety symptoms]
Sleep: [Description of patient's sleep patterns and any related symptoms]
Appetite: [Description of patient's appetite]
Suicidal and homicidal ideations: [Patient's report of suicidal or homicidal ideations or plans]
Auditory and visual hallucinations: [Patient's report of auditory or visual hallucinations]
Delusions/paranoia: [Description of any delusional or paranoid thinking exhibited by the patient]
Manic symptoms: [Patient's report of manic symptoms]

Past Psychiatric History:
- Prior diagnosis: [Patient's prior psychiatric diagnoses]
- Hospitalizations in psychiatric units: [Patient's history of psychiatric hospitalizations]
- Previous suicide attempts: [Patient's history of suicide attempts]
- History of self harm: [Patient's history of self-harm behaviors]
- Access to firearms: [Patient's access to firearms]
- Psychotropic medications: [Patient's current or past use of psychotropic medications]
- Current psychiatrist and therapist: [Patient's current mental health care providers]
- Cures report: [Availability of patient's CURES report]

Family History of psychiatric/substance use history: [Patient's family history of psychiatric or substance use disorders]

Substance Use History:
- Alcohol: [Patient's alcohol use history and patterns]
- Cannabis: [Patient's cannabis use history]
- Amphetamines: [Patient's amphetamine use history]
- Nicotine: [Patient's nicotine use history]
- Other substances: [Patient's use of other substances]

Medical History: [Patient's reported medical history]

Medical Review of systems: [Results of patient's medical review of systems]

Current Medications: [Patient's current medications]

Allergies: [Patient's known allergies]

Social History:
- Marital Status: [Patient's marital status]
- Children: [Number and ages of patient's children, if applicable]
- Living situation: [Patient's current living situation]
- Employment: [Patient's employment status and details]
- Education: [Patient's educational background]
- Support System: [Patient's support system, including family and friends]

Objective:
Mental Status Evaluation:
Appearance: [Description of patient's appearance]
Cognition: [Assessment of patient's cognitive functioning]
Speech: [Description of patient's speech patterns]
Mood: [Patient's reported mood]
Affect: [Description of patient's affect]
TP: [Assessment of patient's thought process]
TC: [Assessment of patient's thought content, including suicidal/homicidal ideations and delusions]
Perc: [Assessment of patient's perceptual disturbances, including auditory/visual hallucinations]
Insight/Judgment: [Assessment of patient's insight and judgment]

Assessment:
[Summary of patient's presentation, target symptoms, and diagnostic impressions]

Plan:
1. Risk Assessment: [Assessment of patient's risk for danger to self or others, including protective factors and safety planning]
2. Status: [Patient's treatment status (e.g., voluntary, involuntary)]
3. Diagnostics: [Diagnostic tests or referrals, if applicable]
4. Treatment:
5. Bio: [Biological interventions, including medication management and discussion of risks/benefits/side effects]
6. Psychosocial: [Psychosocial interventions, including therapy modalities, safety planning, and referrals]
7. Patient's Participation in treatment plan: [Patient's understanding and willingness to engage in treatment]

Therapeutic Interventions: [Type of therapy/approach used and duration of session]
Symptoms or Challenges Discussed: [Specific symptoms or challenges addressed in the therapy session]
Impact on the Patient's Functioning: [Description of how the patient's symptoms impact their functioning]
Specific Topics Covered: [Topics discussed during the therapy session]
Client's Response: [Patient's response to the therapeutic interventions]
Prognosis: [Assessment of patient's prognosis and risk for decompensation]

Diagnosis:
[Patient's psychiatric diagnoses with ICD-10 codes]

Billing Codes:
[Applicable billing codes for the services provided]

Provider's name:
[Provider's name]