Assignment Prompt & Instructions
**files (2)**
– ## SOAPPsychiatricFollow-up28129.pdf
– ## 7_Additional_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Behavior: Calm, cooperative, guarded, agitated, withdrawn, restless, distracted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_Additional_Mental_Health_Charts.docx**
## Additional Mental Health Patient Charts
### Chart 8
**Age:** 27
**Race:** Black/African American
**Gender:** Male
**Chief Complaint:** I feel overwhelmed and stressed.
**HPI:** Patient reports excessive stress related to work demands, irritability, fatigue, and poor sleep for 2 months. Denies SI/HI/AH/VH.
**CPT 9:** 90834
**CPT 10:** 99213
**ICD-9:** 309.24
**Medication:** Buspirone 5 mg PO BID
**Education:** Discussed stress management, healthy coping mechanisms, sleep hygiene, relaxation exercises, and medication adherence.
### Chart 9
**Age:** 58
**Race:** Hispanic
**Gender:** Female
**Chief Complaint:** I keep reliving my trauma.
**HPI:** Patient reports nightmares, flashbacks, hypervigilance, and avoidance behaviors following a motor vehicle accident 1 year ago. Denies SI/HI.
**CPT 9:** 90837
**CPT 10:** 99214
**ICD-9:** 309.81
**Medication:** Prazosin 1 mg PO at bedtime
**Education:** Reviewed PTSD symptoms, grounding techniques, trauma-focused therapy options, medication side effects, and safety planning.
### Chart 10
**Age:** 19
**Race:** White
**Gender:** Female
**Chief Complaint:** I panic in social situations.
**HPI:** Patient reports intense fear during social interactions, avoidance of public speaking, sweating, trembling, and nausea when around groups. Symptoms ongoing for several years.
**CPT 9:** 90832
**CPT 10:** 99213
**ICD-9:** 300.23
**Medication:** Fluoxetine 10 mg PO daily
**Education:** Discussed social anxiety management, cognitive behavioral therapy, gradual exposure techniques, and medication compliance.
### Chart 11
**Age:** 47
**Race:** Asian
**Gender:** Male
**Chief Complaint:** I hear voices sometimes.
**HPI:** Patient reports auditory hallucinations, paranoia, social withdrawal, and poor sleep for several months. Denies command hallucinations or SI/HI.
**CPT 9:** 90837
**CPT 10:** 99215
**ICD-9:** 295.90
**Medication:** Risperidone 1 mg PO at bedtime
**Education:** Reviewed psychosis symptoms, medication adherence, importance of family support, crisis intervention resources, and follow-up care.
### Chart 12
**Age:** 36
**Race:** Native American
**Gender:** Female
**Chief Complaint:** My mood changes quickly.
**HPI:** Patient reports unstable relationships, emotional outbursts, impulsive spending, and chronic feelings of emptiness. Denies current SI/HI.
**CPT 9:** 90834
**CPT 10:** 99214
**ICD-9:** 301.83
**Medication:** Aripiprazole 2 mg PO daily
**Education:** Discussed emotional regulation skills, dialectical behavioral therapy, medication monitoring, and coping strategies.
### Chart 13
**Age:** 65
**Race:** White
**Gender:** Male
**Chief Complaint:** I forget things often.
**HPI:** Patient reports progressive forgetfulness, misplacing items, and difficulty remembering appointments over the past year. Family reports mild confusion at times.
**CPT 9:** 96116
**CPT 10:** 99214
**ICD-9:** 331.83
**Medication:** Donepezil 5 mg PO daily
**Education:** Reviewed memory support strategies, medication administration, caregiver support, home safety, and follow-up evaluations.
### Chart 14
**Age:** 31
**Race:** Middle Eastern
**Gender:** Female
**Chief Complaint:** I cannot stop checking things.
**HPI:** Patient reports repetitive handwashing, checking locks multiple times daily, and intrusive thoughts interfering with daily functioning. Symptoms present for several years.
**CPT 9:** 90837
**CPT 10:** 99214
**ICD-9:** 300.3
**Medication:** Fluvoxamine 50 mg PO at bedtime
**Education:** Discussed obsessive-compulsive disorder symptoms, exposure response prevention therapy, medication side effects, and stress reduction techniques.
**## 7_Additional_Mental_Health_Charts.docx**
## Additional Mental Health Patient Charts
### Chart 8
**Age:** 27
**Race:** Black/African American
**Gender:** Male
**Chief Complaint:** I feel overwhelmed and stressed.
**HPI:** Patient reports excessive stress related to work demands, irritability, fatigue, and poor sleep for 2 months. Denies SI/HI/AH/VH.
**CPT 9:** 90834
**CPT 10:** 99213
**ICD-9:** 309.24
**Medication:** Buspirone 5 mg PO BID
**Education:** Discussed stress management, healthy coping mechanisms, sleep hygiene, relaxation exercises, and medication adherence.
### Chart 9
**Age:** 58
**Race:** Hispanic
**Gender:** Female
**Chief Complaint:** I keep reliving my trauma.
**HPI:** Patient reports nightmares, flashbacks, hypervigilance, and avoidance behaviors following a motor vehicle accident 1 year ago. Denies SI/HI.
**CPT 9:** 90837
**CPT 10:** 99214
**ICD-9:** 309.81
**Medication:** Prazosin 1 mg PO at bedtime
**Education:** Reviewed PTSD symptoms, grounding techniques, trauma-focused therapy options, medication side effects, and safety planning.
### Chart 10
**Age:** 19
**Race:** White
**Gender:** Female
**Chief Complaint:** I panic in social situations.
**HPI:** Patient reports intense fear during social interactions, avoidance of public speaking, sweating, trembling, and nausea when around groups. Symptoms ongoing for several years.
**CPT 9:** 90832
**CPT 10:** 99213
**ICD-9:** 300.23
**Medication:** Fluoxetine 10 mg PO daily
**Education:** Discussed social anxiety management, cognitive behavioral therapy, gradual exposure techniques, and medication compliance.
### Chart 11
**Age:** 47
**Race:** Asian
**Gender:** Male
**Chief Complaint:** I hear voices sometimes.
**HPI:** Patient reports auditory hallucinations, paranoia, social withdrawal, and poor sleep for several months. Denies command hallucinations or SI/HI.
**CPT 9:** 90837
**CPT 10:** 99215
**ICD-9:** 295.90
**Medication:** Risperidone 1 mg PO at bedtime
**Education:** Reviewed psychosis symptoms, medication adherence, importance of family support, crisis intervention resources, and follow-up care.
### Chart 12
**Age:** 36
**Race:** Native American
**Gender:** Female
**Chief Complaint:** My mood changes quickly.
**HPI:** Patient reports unstable relationships, emotional outbursts, impulsive spending, and chronic feelings of emptiness. Denies current SI/HI.
**CPT 9:** 90834
**CPT 10:** 99214
**ICD-9:** 301.83
**Medication:** Aripiprazole 2 mg PO daily
**Education:** Discussed emotional regulation skills, dialectical behavioral therapy, medication monitoring, and coping strategies.
### Chart 13
**Age:** 65
**Race:** White
**Gender:** Male
**Chief Complaint:** I forget things often.
**HPI:** Patient reports progressive forgetfulness, misplacing items, and difficulty remembering appointments over the past year. Family reports mild confusion at times.
**CPT 9:** 96116
**CPT 10:** 99214
**ICD-9:** 331.83
**Medication:** Donepezil 5 mg PO daily
**Education:** Reviewed memory support strategies, medication administration, caregiver support, home safety, and follow-up evaluations.
### Chart 14
**Age:** 31
**Race:** Middle Eastern
**Gender:** Female
**Chief Complaint:** I cannot stop checking things.
**HPI:** Patient reports repetitive handwashing, checking locks multiple times daily, and intrusive thoughts interfering with daily functioning. Symptoms present for several years.
**CPT 9:** 90837
**CPT 10:** 99214
**ICD-9:** 300.3
**Medication:** Fluvoxamine 50 mg PO at bedtime
**Education:** Discussed obsessive-compulsive disorder symptoms, exposure response prevention therapy, medication side effects, and stress reduction techniques.
**## 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_Additional_Mental_Health_Charts.docx**
## Additional Mental Health Patient Charts
### Chart 8
**Age:** 27
**Race:** Black/African American
**Gender:** Male
**Chief Complaint:** I feel overwhelmed and stressed.
**HPI:** Patient reports excessive stress related to work demands, irritability, fatigue, and poor sleep for 2 months. Denies SI/HI/AH/VH.
**CPT 9:** 90834
**CPT 10:** 99213
**ICD-9:** 309.24
**Medication:** Buspirone 5 mg PO BID
**Education:** Discussed stress management, healthy coping mechanisms, sleep hygiene, relaxation exercises, and medication adherence.
### Chart 9
**Age:** 58
**Race:** Hispanic
**Gender:** Female
**Chief Complaint:** I keep reliving my trauma.
**HPI:** Patient reports nightmares, flashbacks, hypervigilance, and avoidance behaviors following a motor vehicle accident 1 year ago. Denies SI/HI.
**CPT 9:** 90837
**CPT 10:** 99214
**ICD-9:** 309.81
**Medication:** Prazosin 1 mg PO at bedtime
**Education:** Reviewed PTSD symptoms, grounding techniques, trauma-focused therapy options, medication side effects, and safety planning.
### Chart 10
**Age:** 19
**Race:** White
**Gender:** Female
**Chief Complaint:** I panic in social situations.
**HPI:** Patient reports intense fear during social interactions, avoidance of public speaking, sweating, trembling, and nausea when around groups. Symptoms ongoing for several years.
**CPT 9:** 90832
**CPT 10:** 99213
**ICD-9:** 300.23
**Medication:** Fluoxetine 10 mg PO daily
**Education:** Discussed social anxiety management, cognitive behavioral therapy, gradual exposure techniques, and medication compliance.
### Chart 11
**Age:** 47
**Race:** Asian
**Gender:** Male
**Chief Complaint:** I hear voices sometimes.
**HPI:** Patient reports auditory hallucinations, paranoia, social withdrawal, and poor sleep for several months. Denies command hallucinations or SI/HI.
**CPT 9:** 90837
**CPT 10:** 99215
**ICD-9:** 295.90
**Medication:** Risperidone 1 mg PO at bedtime
**Education:** Reviewed psychosis symptoms, medication adherence, importance of family support, crisis intervention resources, and follow-up care.
### Chart 12
**Age:** 36
**Race:** Native American
**Gender:** Female
**Chief Complaint:** My mood changes quickly.
**HPI:** Patient reports unstable relationships, emotional outbursts, impulsive spending, and chronic feelings of emptiness. Denies current SI/HI.
**CPT 9:** 90834
**CPT 10:** 99214
**ICD-9:** 301.83
**Medication:** Aripiprazole 2 mg PO daily
**Education:** Discussed emotional regulation skills, dialectical behavioral therapy, medication monitoring, and coping strategies.
### Chart 13
**Age:** 65
**Race:** White
**Gender:** Male
**Chief Complaint:** I forget things often.
**HPI:** Patient reports progressive forgetfulness, misplacing items, and difficulty remembering appointments over the past year. Family reports mild confusion at times.
**CPT 9:** 96116
**CPT 10:** 99214
**ICD-9:** 331.83
**Medication:** Donepezil 5 mg PO daily
**Education:** Reviewed memory support strategies, medication administration, caregiver support, home safety, and follow-up evaluations.
### Chart 14
**Age:** 31
**Race:** Middle Eastern
**Gender:** Female
**Chief Complaint:** I cannot stop checking things.
**HPI:** Patient reports repetitive handwashing, checking locks multiple times daily, and intrusive thoughts interfering with daily functioning. Symptoms present for several years.
**CPT 9:** 90837
**CPT 10:** 99214
**ICD-9:** 300.3
**Medication:** Fluvoxamine 50 mg PO at bedtime
**Education:** Discussed obsessive-compulsive disorder symptoms, exposure response prevention therapy, medication side effects, and stress reduction techniques.
**## 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_Additional_Mental_Health_Charts.docx**
## Additional Mental Health Patient Charts
### Chart 8
**Age:** 27
**Race:** Black/African American
**Gender:** Male
**Chief Complaint:** I feel overwhelmed and stressed.
**HPI:** Patient reports excessive stress related to work demands, irritability, fatigue, and poor sleep for 2 months. Denies SI/HI/AH/VH.
**CPT 9:** 90834
**CPT 10:** 99213
**ICD-9:** 309.24
**Medication:** Buspirone 5 mg PO BID
**Education:** Discussed stress management, healthy coping mechanisms, sleep hygiene, relaxation exercises, and medication adherence.
### Chart 9
**Age:** 58
**Race:** Hispanic
**Gender:** Female
**Chief Complaint:** I keep reliving my trauma.
**HPI:** Patient reports nightmares, flashbacks, hypervigilance, and avoidance behaviors following a motor vehicle accident 1 year ago. Denies SI/HI.
**CPT 9:** 90837
**CPT 10:** 99214
**ICD-9:** 309.81
**Medication:** Prazosin 1 mg PO at bedtime
**Education:** Reviewed PTSD symptoms, grounding techniques, trauma-focused therapy options, medication side effects, and safety planning.
### Chart 10
**Age:** 19
**Race:** White
**Gender:** Female
**Chief Complaint:** I panic in social situations.
**HPI:** Patient reports intense fear during social interactions, avoidance of public speaking, sweating, trembling, and nausea when around groups. Symptoms ongoing for several years.
**CPT 9:** 90832
**CPT 10:** 99213
**ICD-9:** 300.23
**Medication:** Fluoxetine 10 mg PO daily
**Education:** Discussed social anxiety management, cognitive behavioral therapy, gradual exposure techniques, and medication compliance.
### Chart 11
**Age:** 47
**Race:** Asian
**Gender:** Male
**Chief Complaint:** I hear voices sometimes.
**HPI:** Patient reports auditory hallucinations, paranoia, social withdrawal, and poor sleep for several months. Denies command hallucinations or SI/HI.
**CPT 9:** 90837
**CPT 10:** 99215
**ICD-9:** 295.90
**Medication:** Risperidone 1 mg PO at bedtime
**Education:** Reviewed psychosis symptoms, medication adherence, importance of family support, crisis intervention resources, and follow-up care.
### Chart 12
**Age:** 36
**Race:** Native American
**Gender:** Female
**Chief Complaint:** My mood changes quickly.
**HPI:** Patient reports unstable relationships, emotional outbursts, impulsive spending, and chronic feelings of emptiness. Denies current SI/HI.
**CPT 9:** 90834
**CPT 10:** 99214
**ICD-9:** 301.83
**Medication:** Aripiprazole 2 mg PO daily
**Education:** Discussed emotional regulation skills, dialectical behavioral therapy, medication monitoring, and coping strategies.
### Chart 13
**Age:** 65
**Race:** White
**Gender:** Male
**Chief Complaint:** I forget things often.
**HPI:** Patient reports progressive forgetfulness, misplacing items, and difficulty remembering appointments over the past year. Family reports mild confusion at times.
**CPT 9:** 96116
**CPT 10:** 99214
**ICD-9:** 331.83
**Medication:** Donepezil 5 mg PO daily
**Education:** Reviewed memory support strategies, medication administration, caregiver support, home safety, and follow-up evaluations.
### Chart 14
**Age:** 31
**Race:** Middle Eastern
**Gender:** Female
**Chief Complaint:** I cannot stop checking things.
**HPI:** Patient reports repetitive handwashing, checking locks multiple times daily, and intrusive thoughts interfering with daily functioning. Symptoms present for several years.
**CPT 9:** 90837
**CPT 10:** 99214
**ICD-9:** 300.3
**Medication:** Fluvoxamine 50 mg PO at bedtime
**Education:** Discussed obsessive-compulsive disorder symptoms, exposure response prevention therapy, medication side effects, and stress reduction techniques.