[Solved] Bb 7 soap note

Assignment Prompt & Instructions

**files (2)**

– ## SOAPPsychiatricFollow-up28129.pdf

– ## 7_Mental_Health_Charts.docx

**## SOAPPsychiatricFollow-up28129.pdf**

SOAP Note (Psychiatric Follow-up Template)

S-Subjective:

Client identifying information: Patient’s Initial, DOB, other identifying information

Chief Compliant: “Stated in the patient’s own words”

History of Present Illness: Timing of symptoms (when did symptoms begin), quality,
severity, setting, aggravating factors, associated symptoms? What has been helpful in
alleviating symptoms?

The OLD CARTS mnemonic is a structured clinical tool used to guide the History of
Present Illness by systematically capturing key dimensions: Onset (when the symptom
began), Location (where it’s felt), Duration (how long or often it occurs), Character
(what it feels like), Aggravating/Alleviating factors (what makes it worse or better),
Radiation/Relief (whether it spreads or what relieves it), Timing (patterns or
frequency), and Severity (how intense and how it affects daily life).

Sleep: quality, amount

Appetite and weight: Increased/decreased, gain/loss

Psychomotor agitation/retardation: agitated, feel sluggish

Anhedonia: unable to master interest as before

Concentration: unable to concentrate/think clearly about things

Guilt/Worthlessness: sense of guilt or worthlessness

Medication Side effects: What are the side effects

Note this should be written in a paragraph.

PAST MEDICAL, FAMILY, AND SOCIAL HISTORY UPDATE (including substance
use): State the patient’s current employment status, substance use (current/history),
overall health condition, and present living situation.”

Prior substance abuse treatment programs (detox, rehab, IOP): Denied
Alcohol (blackouts, tremors, seizures): Denied
Sedatives or sleeping pills (benzos, Ambien): Denied
Opioids (pills, heroin, kratom, overdoses, IV drug use, MAT): Denied
Cannabis: Medical uses
Nicotine: Denied
Cocaine: Denied
Methamphetamine: Denied
Stimulant medications: Denied
Hallucinogens (LSD, mushrooms, salvia): Denied
Club drugs (ecstasy, ketamine, PCP, GHB): Denied
Other (steroids, bath salts, Spice/K2): Denied
Longest time sober (without any substance use other than nicotine): N/A
Payment history (work, drug dealing, stealing, trading sex): Denied

O-Objective:

MENTAL STATUS EXAM:

Appearance: Well-groomed, disheveled, older than stated age, malodorous,
appropriately dressed

Behavior: Calm, cooperative, guarded, agitated, withdrawn, restless, distracted

Speech: Normal rate/rhythm, pressured, slow, monotone, loud, soft, slurred, articulate

Mood (subjective) “Depressed,” “anxious,” “angry,” “okay,” “hopeless,” “irritable,”
“numb”

Affect: (objective) Congruent/incongruent with mood, flat, blunted, labile, restricted,
full range

Thought Process: Logical, linear, goal-directed, tangential, circumstantial,
disorganized, flight of ideas

Thought Content: Normal, suicidal ideation, homicidal ideation, obsessive thoughts,
paranoid, delusional

Perception: No hallucinations, auditory hallucinations, visual hallucinations, illusions

Cognition: Alert, oriented ×3 (person/place/time), oriented ×4 (+situation),
disoriented

Attention/Concentration: Intact, easily distracted, impaired, unable to spell “world”
backwards

Memory: Intact, short-term impaired, recent impaired, remote memory intact

Insight: Good, fair, poor, lacks awareness of illness

Judgment: Intact, impaired, poor, limited, impulsive

Reliability: Reliable historian, questionable reliability, vague or evasive responses

Other Objective Information:

Vital Signs, Height, Weight, BMI, EKG, (any psychological testing if available).

Screening Tools: PHQ9, GAD7, Beck Depression Inventory etc.

LABS/Pregnancy Test/Toxicology:

CURRENT MEDICATIONS:

Psychotropic:

Non-psychiatric:

Vitamins and supplements:

A-ASSESSMENT:

Restate symptoms reported in HPI in a short paragraph.

Primary Psychiatric Diagnosis with specifier (if known), severity, when applicable,
ICD-10. (List Criteria as stated in the DSM V-TR, identify which are MET and or NOT
MET and provide 1-2 sentences to provide explanation/rationale.

Medical diagnoses if known:

Contextual Factors (Z codes): External influences that impact a patient’s mental
health but are not mental disorders; they provide psychosocial, environmental, and
situational stressors (e.g. homelessness, problems in relationship with a spouse or
partner).

List one differential diagnosis, other disorders that are similar in nature such as
criteria, so should be considered in the case. Provide a brief explanation of the
rationale.

Visit code:

Time Spent with patient:

Type of visit: Face to Face in office visit/Telehealth-virtual visit/etc.

**## 7_Mental_Health_Charts.docx**

## Mental Health Patient Charts

### Chart 1

**Age:** 34

**Race:** African American

**Gender:** Female

**Chief Complaint:** I feel anxious all the time.

**HPI:** Patient reports excessive worry, restlessness, muscle tension, and difficulty sleeping for 4 months. Denies SI/HI/AH/VH.

**CPT 9:** 90837

**CPT 10:** 99214

**ICD-9:** 300.02

**Medication:** Sertraline 25 mg PO daily

**Education:** Reviewed anxiety triggers, sleep hygiene, coping skills, medication side effects, and emergency resources.

### Chart 2

**Age:** 42

**Race:** White

**Gender:** Male

**Chief Complaint:** I have no motivation.

**HPI:** Patient reports low mood, fatigue, poor concentration, and decreased interest for 6 weeks. Denies SI/HI/AH/VH.

**CPT 9:** 90834

**CPT 10:** 99213

**ICD-9:** 311

**Medication:** Escitalopram 5 mg PO daily

**Education:** Discussed depression symptoms, medication adherence, therapy benefits, exercise, and crisis plan.

### Chart 3

**Age:** 29

**Race:** Hispanic

**Gender:** Female

**Chief Complaint:** I cannot focus at work.

**HPI:** Patient reports distractibility, poor task completion, forgetfulness, and difficulty organizing responsibilities since childhood, worsened recently.

**CPT 9:** 96127

**CPT 10:** 99214

**ICD-9:** 314.00

**Medication:** Atomoxetine 40 mg PO daily

**Education:** Reviewed ADHD coping strategies, medication risks/benefits, routine building, and follow-up monitoring.

### Chart 4

**Age:** 51

**Race:** African American

**Gender:** Male

**Chief Complaint:** I am not sleeping.

**HPI:** Patient reports difficulty falling and staying asleep for 3 months, daytime fatigue, and irritability. Denies SI/HI/AH/VH.

**CPT 9:** 90832

**CPT 10:** 99213

**ICD-9:** 780.52

**Medication:** Trazodone 50 mg PO at bedtime

**Education:** Reviewed sleep hygiene, avoiding alcohol before bed, medication safety, and relaxation techniques.

### Chart 5

**Age:** 38

**Race:** Asian

**Gender:** Female

**Chief Complaint:** My moods go up and down.

**HPI:** Patient reports periods of elevated energy, decreased need for sleep, racing thoughts, followed by depressive episodes. Denies current SI/HI.

**CPT 9:** 90837

**CPT 10:** 99214

**ICD-9:** 296.80

**Medication:** Lamotrigine 25 mg PO daily

**Education:** Reviewed mood tracking, rash warning, medication adherence, sleep routine, and emergency symptoms.

### Chart 6

**Age:** 46

**Race:** Native American

**Gender:** Male

**Chief Complaint:** I keep having panic attacks.

**HPI:** Patient reports sudden episodes of chest tightness, shortness of breath, trembling, and fear of dying occurring 2–3 times weekly.

**CPT 9:** 90834

**CPT 10:** 99214

**ICD-9:** 300.01

**Medication:** Hydroxyzine 25 mg PO BID PRN anxiety

**Education:** Taught grounding skills, breathing exercises, panic attack education, medication precautions, and ER precautions.

### Chart 7

**Age:** 63

**Race:** White

**Gender:** Female

**Chief Complaint:** I feel sad since my husband passed.

**HPI:** Patient reports grief, tearfulness, loneliness, poor appetite, and sleep disturbance after spouse’s death 5 months ago. Denies SI/HI/AH/VH.

**CPT 9:** 90837

**CPT 10:** 99213

**ICD-9:** 309.0

**Medication:** Mirtazapine 7.5 mg PO at bedtime

**Education:** Discussed grief counseling, nutrition, sleep support, medication effects, social support, and safety planning.

**## 7_Mental_Health_Charts.docx**

## Mental Health Patient Charts

### Chart 1

**Age:** 34

**Race:** African American

**Gender:** Female

**Chief Complaint:** I feel anxious all the time.

**HPI:** Patient reports excessive worry, restlessness, muscle tension, and difficulty sleeping for 4 months. Denies SI/HI/AH/VH.

**CPT 9:** 90837

**CPT 10:** 99214

**ICD-9:** 300.02

**Medication:** Sertraline 25 mg PO daily

**Education:** Reviewed anxiety triggers, sleep hygiene, coping skills, medication side effects, and emergency resources.

### Chart 2

**Age:** 42

**Race:** White

**Gender:** Male

**Chief Complaint:** I have no motivation.

**HPI:** Patient reports low mood, fatigue, poor concentration, and decreased interest for 6 weeks. Denies SI/HI/AH/VH.

**CPT 9:** 90834

**CPT 10:** 99213

**ICD-9:** 311

**Medication:** Escitalopram 5 mg PO daily

**Education:** Discussed depression symptoms, medication adherence, therapy benefits, exercise, and crisis plan.

### Chart 3

**Age:** 29

**Race:** Hispanic

**Gender:** Female

**Chief Complaint:** I cannot focus at work.

**HPI:** Patient reports distractibility, poor task completion, forgetfulness, and difficulty organizing responsibilities since childhood, worsened recently.

**CPT 9:** 96127

**CPT 10:** 99214

**ICD-9:** 314.00

**Medication:** Atomoxetine 40 mg PO daily

**Education:** Reviewed ADHD coping strategies, medication risks/benefits, routine building, and follow-up monitoring.

### Chart 4

**Age:** 51

**Race:** African American

**Gender:** Male

**Chief Complaint:** I am not sleeping.

**HPI:** Patient reports difficulty falling and staying asleep for 3 months, daytime fatigue, and irritability. Denies SI/HI/AH/VH.

**CPT 9:** 90832

**CPT 10:** 99213

**ICD-9:** 780.52

**Medication:** Trazodone 50 mg PO at bedtime

**Education:** Reviewed sleep hygiene, avoiding alcohol before bed, medication safety, and relaxation techniques.

### Chart 5

**Age:** 38

**Race:** Asian

**Gender:** Female

**Chief Complaint:** My moods go up and down.

**HPI:** Patient reports periods of elevated energy, decreased need for sleep, racing thoughts, followed by depressive episodes. Denies current SI/HI.

**CPT 9:** 90837

**CPT 10:** 99214

**ICD-9:** 296.80

**Medication:** Lamotrigine 25 mg PO daily

**Education:** Reviewed mood tracking, rash warning, medication adherence, sleep routine, and emergency symptoms.

### Chart 6

**Age:** 46

**Race:** Native American

**Gender:** Male

**Chief Complaint:** I keep having panic attacks.

**HPI:** Patient reports sudden episodes of chest tightness, shortness of breath, trembling, and fear of dying occurring 2–3 times weekly.

**CPT 9:** 90834

**CPT 10:** 99214

**ICD-9:** 300.01

**Medication:** Hydroxyzine 25 mg PO BID PRN anxiety

**Education:** Taught grounding skills, breathing exercises, panic attack education, medication precautions, and ER precautions.

### Chart 7

**Age:** 63

**Race:** White

**Gender:** Female

**Chief Complaint:** I feel sad since my husband passed.

**HPI:** Patient reports grief, tearfulness, loneliness, poor appetite, and sleep disturbance after spouse’s death 5 months ago. Denies SI/HI/AH/VH.

**CPT 9:** 90837

**CPT 10:** 99213

**ICD-9:** 309.0

**Medication:** Mirtazapine 7.5 mg PO at bedtime

**Education:** Discussed grief counseling, nutrition, sleep support, medication effects, social support, and safety planning.

**## SOAPPsychiatricFollow-up28129.pdf**

SOAP Note (Psychiatric Follow-up Template)

S-Subjective:

Client identifying information: Patient’s Initial, DOB, other identifying information

Chief Compliant: “Stated in the patient’s own words”

History of Present Illness: Timing of symptoms (when did symptoms begin), quality,
severity, setting, aggravating factors, associated symptoms? What has been helpful in
alleviating symptoms?

The OLD CARTS mnemonic is a structured clinical tool used to guide the History of
Present Illness by systematically capturing key dimensions: Onset (when the symptom
began), Location (where it’s felt), Duration (how long or often it occurs), Character
(what it feels like), Aggravating/Alleviating factors (what makes it worse or better),
Radiation/Relief (whether it spreads or what relieves it), Timing (patterns or
frequency), and Severity (how intense and how it affects daily life).

Sleep: quality, amount

Appetite and weight: Increased/decreased, gain/loss

Psychomotor agitation/retardation: agitated, feel sluggish

Anhedonia: unable to master interest as before

Concentration: unable to concentrate/think clearly about things

Guilt/Worthlessness: sense of guilt or worthlessness

Medication Side effects: What are the side effects

Note this should be written in a paragraph.

PAST MEDICAL, FAMILY, AND SOCIAL HISTORY UPDATE (including substance
use): State the patient’s current employment status, substance use (current/history),
overall health condition, and present living situation.”

Prior substance abuse treatment programs (detox, rehab, IOP): Denied
Alcohol (blackouts, tremors, seizures): Denied
Sedatives or sleeping pills (benzos, Ambien): Denied
Opioids (pills, heroin, kratom, overdoses, IV drug use, MAT): Denied
Cannabis: Medical uses
Nicotine: Denied
Cocaine: Denied
Methamphetamine: Denied
Stimulant medications: Denied
Hallucinogens (LSD, mushrooms, salvia): Denied
Club drugs (ecstasy, ketamine, PCP, GHB): Denied
Other (steroids, bath salts, Spice/K2): Denied
Longest time sober (without any substance use other than nicotine): N/A
Payment history (work, drug dealing, stealing, trading sex): Denied

O-Objective:

MENTAL STATUS EXAM:

Appearance: Well-groomed, disheveled, older than stated age, malodorous,
appropriately dressed

Behavior: Calm, cooperative, guarded, agitated, withdrawn, restless, distracted

Speech: Normal rate/rhythm, pressured, slow, monotone, loud, soft, slurred, articulate

Mood (subjective) “Depressed,” “anxious,” “angry,” “okay,” “hopeless,” “irritable,”
“numb”

Affect: (objective) Congruent/incongruent with mood, flat, blunted, labile, restricted,
full range

Thought Process: Logical, linear, goal-directed, tangential, circumstantial,
disorganized, flight of ideas

Thought Content: Normal, suicidal ideation, homicidal ideation, obsessive thoughts,
paranoid, delusional

Perception: No hallucinations, auditory hallucinations, visual hallucinations, illusions

Cognition: Alert, oriented ×3 (person/place/time), oriented ×4 (+situation),
disoriented

Attention/Concentration: Intact, easily distracted, impaired, unable to spell “world”
backwards

Memory: Intact, short-term impaired, recent impaired, remote memory intact

Insight: Good, fair, poor, lacks awareness of illness

Judgment: Intact, impaired, poor, limited, impulsive

Reliability: Reliable historian, questionable reliability, vague or evasive responses

Other Objective Information:

Vital Signs, Height, Weight, BMI, EKG, (any psychological testing if available).

Screening Tools: PHQ9, GAD7, Beck Depression Inventory etc.

LABS/Pregnancy Test/Toxicology:

CURRENT MEDICATIONS:

Psychotropic:

Non-psychiatric:

Vitamins and supplements:

A-ASSESSMENT:

Restate symptoms reported in HPI in a short paragraph.

Primary Psychiatric Diagnosis with specifier (if known), severity, when applicable,
ICD-10. (List Criteria as stated in the DSM V-TR, identify which are MET and or NOT
MET and provide 1-2 sentences to provide explanation/rationale.

Medical diagnoses if known:

Contextual Factors (Z codes): External influences that impact a patient’s mental
health but are not mental disorders; they provide psychosocial, environmental, and
situational stressors (e.g. homelessness, problems in relationship with a spouse or
partner).

List one differential diagnosis, other disorders that are similar in nature such as
criteria, so should be considered in the case. Provide a brief explanation of the
rationale.

Visit code:

Time Spent with patient:

Type of visit: Face to Face in office visit/Telehealth-virtual visit/etc.

**## 7_Mental_Health_Charts.docx**

## Mental Health Patient Charts

### Chart 1

**Age:** 34

**Race:** African American

**Gender:** Female

**Chief Complaint:** I feel anxious all the time.

**HPI:** Patient reports excessive worry, restlessness, muscle tension, and difficulty sleeping for 4 months. Denies SI/HI/AH/VH.

**CPT 9:** 90837

**CPT 10:** 99214

**ICD-9:** 300.02

**Medication:** Sertraline 25 mg PO daily

**Education:** Reviewed anxiety triggers, sleep hygiene, coping skills, medication side effects, and emergency resources.

### Chart 2

**Age:** 42

**Race:** White

**Gender:** Male

**Chief Complaint:** I have no motivation.

**HPI:** Patient reports low mood, fatigue, poor concentration, and decreased interest for 6 weeks. Denies SI/HI/AH/VH.

**CPT 9:** 90834

**CPT 10:** 99213

**ICD-9:** 311

**Medication:** Escitalopram 5 mg PO daily

**Education:** Discussed depression symptoms, medication adherence, therapy benefits, exercise, and crisis plan.

### Chart 3

**Age:** 29

**Race:** Hispanic

**Gender:** Female

**Chief Complaint:** I cannot focus at work.

**HPI:** Patient reports distractibility, poor task completion, forgetfulness, and difficulty organizing responsibilities since childhood, worsened recently.

**CPT 9:** 96127

**CPT 10:** 99214

**ICD-9:** 314.00

**Medication:** Atomoxetine 40 mg PO daily

**Education:** Reviewed ADHD coping strategies, medication risks/benefits, routine building, and follow-up monitoring.

### Chart 4

**Age:** 51

**Race:** African American

**Gender:** Male

**Chief Complaint:** I am not sleeping.

**HPI:** Patient reports difficulty falling and staying asleep for 3 months, daytime fatigue, and irritability. Denies SI/HI/AH/VH.

**CPT 9:** 90832

**CPT 10:** 99213

**ICD-9:** 780.52

**Medication:** Trazodone 50 mg PO at bedtime

**Education:** Reviewed sleep hygiene, avoiding alcohol before bed, medication safety, and relaxation techniques.

### Chart 5

**Age:** 38

**Race:** Asian

**Gender:** Female

**Chief Complaint:** My moods go up and down.

**HPI:** Patient reports periods of elevated energy, decreased need for sleep, racing thoughts, followed by depressive episodes. Denies current SI/HI.

**CPT 9:** 90837

**CPT 10:** 99214

**ICD-9:** 296.80

**Medication:** Lamotrigine 25 mg PO daily

**Education:** Reviewed mood tracking, rash warning, medication adherence, sleep routine, and emergency symptoms.

### Chart 6

**Age:** 46

**Race:** Native American

**Gender:** Male

**Chief Complaint:** I keep having panic attacks.

**HPI:** Patient reports sudden episodes of chest tightness, shortness of breath, trembling, and fear of dying occurring 2–3 times weekly.

**CPT 9:** 90834

**CPT 10:** 99214

**ICD-9:** 300.01

**Medication:** Hydroxyzine 25 mg PO BID PRN anxiety

**Education:** Taught grounding skills, breathing exercises, panic attack education, medication precautions, and ER precautions.

### Chart 7

**Age:** 63

**Race:** White

**Gender:** Female

**Chief Complaint:** I feel sad since my husband passed.

**HPI:** Patient reports grief, tearfulness, loneliness, poor appetite, and sleep disturbance after spouse’s death 5 months ago. Denies SI/HI/AH/VH.

**CPT 9:** 90837

**CPT 10:** 99213

**ICD-9:** 309.0

**Medication:** Mirtazapine 7.5 mg PO at bedtime

**Education:** Discussed grief counseling, nutrition, sleep support, medication effects, social support, and safety planning.

**## SOAPPsychiatricFollow-up28129.pdf**

SOAP Note (Psychiatric Follow-up Template)

S-Subjective:

Client identifying information: Patient’s Initial, DOB, other identifying information

Chief Compliant: “Stated in the patient’s own words”

History of Present Illness: Timing of symptoms (when did symptoms begin), quality,
severity, setting, aggravating factors, associated symptoms? What has been helpful in
alleviating symptoms?

The OLD CARTS mnemonic is a structured clinical tool used to guide the History of
Present Illness by systematically capturing key dimensions: Onset (when the symptom
began), Location (where it’s felt), Duration (how long or often it occurs), Character
(what it feels like), Aggravating/Alleviating factors (what makes it worse or better),
Radiation/Relief (whether it spreads or what relieves it), Timing (patterns or
frequency), and Severity (how intense and how it affects daily life).

Sleep: quality, amount

Appetite and weight: Increased/decreased, gain/loss

Psychomotor agitation/retardation: agitated, feel sluggish

Anhedonia: unable to master interest as before

Concentration: unable to concentrate/think clearly about things

Guilt/Worthlessness: sense of guilt or worthlessness

Medication Side effects: What are the side effects

Note this should be written in a paragraph.

PAST MEDICAL, FAMILY, AND SOCIAL HISTORY UPDATE (including substance
use): State the patient’s current employment status, substance use (current/history),
overall health condition, and present living situation.”

Prior substance abuse treatment programs (detox, rehab, IOP): Denied
Alcohol (blackouts, tremors, seizures): Denied
Sedatives or sleeping pills (benzos, Ambien): Denied
Opioids (pills, heroin, kratom, overdoses, IV drug use, MAT): Denied
Cannabis: Medical uses
Nicotine: Denied
Cocaine: Denied
Methamphetamine: Denied
Stimulant medications: Denied
Hallucinogens (LSD, mushrooms, salvia): Denied
Club drugs (ecstasy, ketamine, PCP, GHB): Denied
Other (steroids, bath salts, Spice/K2): Denied
Longest time sober (without any substance use other than nicotine): N/A
Payment history (work, drug dealing, stealing, trading sex): Denied

O-Objective:

MENTAL STATUS EXAM:

Appearance: Well-groomed, disheveled, older than stated age, malodorous,
appropriately dressed

Behavior: Calm, cooperative, guarded, agitated, withdrawn, restless, distracted

Speech: Normal rate/rhythm, pressured, slow, monotone, loud, soft, slurred, articulate

Mood (subjective) “Depressed,” “anxious,” “angry,” “okay,” “hopeless,” “irritable,”
“numb”

Affect: (objective) Congruent/incongruent with mood, flat, blunted, labile, restricted,
full range

Thought Process: Logical, linear, goal-directed, tangential, circumstantial,
disorganized, flight of ideas

Thought Content: Normal, suicidal ideation, homicidal ideation, obsessive thoughts,
paranoid, delusional

Perception: No hallucinations, auditory hallucinations, visual hallucinations, illusions

Cognition: Alert, oriented ×3 (person/place/time), oriented ×4 (+situation),
disoriented

Attention/Concentration: Intact, easily distracted, impaired, unable to spell “world”
backwards

Memory: Intact, short-term impaired, recent impaired, remote memory intact

Insight: Good, fair, poor, lacks awareness of illness

Judgment: Intact, impaired, poor, limited, impulsive

Reliability: Reliable historian, questionable reliability, vague or evasive responses

Other Objective Information:

Vital Signs, Height, Weight, BMI, EKG, (any psychological testing if available).

Screening Tools: PHQ9, GAD7, Beck Depression Inventory etc.

LABS/Pregnancy Test/Toxicology:

CURRENT MEDICATIONS:

Psychotropic:

Non-psychiatric:

Vitamins and supplements:

A-ASSESSMENT:

Restate symptoms reported in HPI in a short paragraph.

Primary Psychiatric Diagnosis with specifier (if known), severity, when applicable,
ICD-10. (List Criteria as stated in the DSM V-TR, identify which are MET and or NOT
MET and provide 1-2 sentences to provide explanation/rationale.

Medical diagnoses if known:

Contextual Factors (Z codes): External influences that impact a patient’s mental
health but are not mental disorders; they provide psychosocial, environmental, and
situational stressors (e.g. homelessness, problems in relationship with a spouse or
partner).

List one differential diagnosis, other disorders that are similar in nature such as
criteria, so should be considered in the case. Provide a brief explanation of the
rationale.

Visit code:

Time Spent with patient:

Type of visit: Face to Face in office visit/Telehealth-virtual visit/etc.

**## 7_Mental_Health_Charts.docx**

## Mental Health Patient Charts

### Chart 1

**Age:** 34

**Race:** African American

**Gender:** Female

**Chief Complaint:** I feel anxious all the time.

**HPI:** Patient reports excessive worry, restlessness, muscle tension, and difficulty sleeping for 4 months. Denies SI/HI/AH/VH.

**CPT 9:** 90837

**CPT 10:** 99214

**ICD-9:** 300.02

**Medication:** Sertraline 25 mg PO daily

**Education:** Reviewed anxiety triggers, sleep hygiene, coping skills, medication side effects, and emergency resources.

### Chart 2

**Age:** 42

**Race:** White

**Gender:** Male

**Chief Complaint:** I have no motivation.

**HPI:** Patient reports low mood, fatigue, poor concentration, and decreased interest for 6 weeks. Denies SI/HI/AH/VH.

**CPT 9:** 90834

**CPT 10:** 99213

**ICD-9:** 311

**Medication:** Escitalopram 5 mg PO daily

**Education:** Discussed depression symptoms, medication adherence, therapy benefits, exercise, and crisis plan.

### Chart 3

**Age:** 29

**Race:** Hispanic

**Gender:** Female

**Chief Complaint:** I cannot focus at work.

**HPI:** Patient reports distractibility, poor task completion, forgetfulness, and difficulty organizing responsibilities since childhood, worsened recently.

**CPT 9:** 96127

**CPT 10:** 99214

**ICD-9:** 314.00

**Medication:** Atomoxetine 40 mg PO daily

**Education:** Reviewed ADHD coping strategies, medication risks/benefits, routine building, and follow-up monitoring.

### Chart 4

**Age:** 51

**Race:** African American

**Gender:** Male

**Chief Complaint:** I am not sleeping.

**HPI:** Patient reports difficulty falling and staying asleep for 3 months, daytime fatigue, and irritability. Denies SI/HI/AH/VH.

**CPT 9:** 90832

**CPT 10:** 99213

**ICD-9:** 780.52

**Medication:** Trazodone 50 mg PO at bedtime

**Education:** Reviewed sleep hygiene, avoiding alcohol before bed, medication safety, and relaxation techniques.

### Chart 5

**Age:** 38

**Race:** Asian

**Gender:** Female

**Chief Complaint:** My moods go up and down.

**HPI:** Patient reports periods of elevated energy, decreased need for sleep, racing thoughts, followed by depressive episodes. Denies current SI/HI.

**CPT 9:** 90837

**CPT 10:** 99214

**ICD-9:** 296.80

**Medication:** Lamotrigine 25 mg PO daily

**Education:** Reviewed mood tracking, rash warning, medication adherence, sleep routine, and emergency symptoms.

### Chart 6

**Age:** 46

**Race:** Native American

**Gender:** Male

**Chief Complaint:** I keep having panic attacks.

**HPI:** Patient reports sudden episodes of chest tightness, shortness of breath, trembling, and fear of dying occurring 2–3 times weekly.

**CPT 9:** 90834

**CPT 10:** 99214

**ICD-9:** 300.01

**Medication:** Hydroxyzine 25 mg PO BID PRN anxiety

**Education:** Taught grounding skills, breathing exercises, panic attack education, medication precautions, and ER precautions.

### Chart 7

**Age:** 63

**Race:** White

**Gender:** Female

**Chief Complaint:** I feel sad since my husband passed.

**HPI:** Patient reports grief, tearfulness, loneliness, poor appetite, and sleep disturbance after spouse’s death 5 months ago. Denies SI/HI/AH/VH.

**CPT 9:** 90837

**CPT 10:** 99213

**ICD-9:** 309.0

**Medication:** Mirtazapine 7.5 mg PO at bedtime

**Education:** Discussed grief counseling, nutrition, sleep support, medication effects, social support, and safety planning.