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follow instuuctions attached – ## soapnoteinstructions.docx – ## soapnoteetemplate.docx **## soapnoteinstructions.docx** Comprehensive Psychotherapy Evaluation 1 1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic. 2. OAP is an acronym that stands for…
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follow instuuctions attached
– ## soapnoteinstructions.docx
– ## soapnoteetemplate.docx
**## soapnoteinstructions.docx**
Comprehensive Psychotherapy Evaluation 1
1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
2. OAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
| | |
| — | — |
| **S =** | Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS) |
| **O =** | Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam |
| **A =** | Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes |
| **P =** | Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up |
**Make it sure it is psychotherapy on a patient with anxiety/depression**
**## soapnoteetemplate.docx**
**Comprehensive Psychiatric Evaluation Template**
**With Psychotherapy Note**
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
**HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
**SI/HI:** _______________________________________________________________________________
**Sleep:**_________________________________________
**Appetite:**\_\_\______________________
**Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________
**Current perception of Health**: Excellent Good Fair Poor
**Psychiatric History:**
**_Inpatient hospitalizations:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_Outpatient psychiatric treatment:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_Detox/Inpatient substance treatment:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_History of suicide attempts and/or self injurious behaviors:_**\_\_\__________________________________
**Past Medical History**
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
**Past Surgical History**\_\_\_________________________________________________________
**_Current psychotropic medications:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_Current prescription medications:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_OTC/Nutritionals/Herbal/Complementary therapy:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_Substance use_** _:_(alcohol, marijuana, cocaine, caffeine, cigarettes)
| | | | |
| — | — | — | — |
| **_Substance_** | **_Amount_** | **_Frequency_** | **_Length of Use_** |
| | | | |
| | | | |
| | | | |
| | | | |
**Family Psychiatric History:** _____________________________________________________
**Social History**
**Lives**: Single family House/Condo/ with stairs: ___________
**Marital Status**:________
**Education**:____________________________
**Employment Status**: ______
**Current/Previous occupation type**: _________________
**Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________
**Sexual Orientation:** _______ Sexual Activity: ____
**Contraception Use**: ____________
**Family Composition:** Family/Mother/Father/Alone
**: _____________________________**
**Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________**
**\_\_\______________________________________________________________________**
**Health Maintenance**
**Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia**
**Exposures:**
**Immunization HX:**
**Review of Systems (at least 3 areas per system):**
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
**Physical Exam**
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
**percentile**) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
**Mental Status Exam**
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
| |
| — |
| **Psychotherapy Note** |
| **Therapeutic Technique Used:** |
| **Session Focus and Theme:** |
| **Intervention Strategies Implemented:** |
| **Evidence of Patient Response**: |
**Plan:**
**Differential Diagnoses**
**1.**
**2.**
**Principal Diagnoses**
**1.**
**2.**
**Plan:**
**Diagnosis #1**
**Diagnostic Testing/Screening:**
**Pharmacological Treatment:**
**Non-Pharmacological Treatment:**
**Patient/Family Education:**
**Referrals:**
**Follow-up:**
**Anticipatory Guidance:**
**Diagnosis #2**
**Diagnostic Testing/Screening Tool:**
**Pharmacological Treatment:**
**Non-Pharmacological Treatment:**
**Patient/Family Education:**
**Referrals:**
**Follow-up:**
**Anticipatory Guidance:**
**Signature (with appropriate credentials): __________________________________________**
**Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________**
**DEA#: 101010101 STU Clinic LIC# 10000000**
**Tel: (000) 555-1234 FAX: (000) 555-12222**
Patient Name: (Initials)______________________________ Age ___________
Date: _______________
**RX ______________________________________**
**SIG:**
**Dispense**: ___________
**Refill:** _________________
**No Substitution**
**Signature:** ____________________________________________________________
**Rev. 2272022 LM**
**## soapnoteetemplate.docx**
**Comprehensive Psychiatric Evaluation Template**
**With Psychotherapy Note**
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
**HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
**SI/HI:** _______________________________________________________________________________
**Sleep:**_________________________________________
**Appetite:**\_\_\______________________
**Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________
**Current perception of Health**: Excellent Good Fair Poor
**Psychiatric History:**
**_Inpatient hospitalizations:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_Outpatient psychiatric treatment:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_Detox/Inpatient substance treatment:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_History of suicide attempts and/or self injurious behaviors:_**\_\_\__________________________________
**Past Medical History**
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
**Past Surgical History**\_\_\_________________________________________________________
**_Current psychotropic medications:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_Current prescription medications:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_OTC/Nutritionals/Herbal/Complementary therapy:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_Substance use_** _:_(alcohol, marijuana, cocaine, caffeine, cigarettes)
| | | | |
| — | — | — | — |
| **_Substance_** | **_Amount_** | **_Frequency_** | **_Length of Use_** |
| | | | |
| | | | |
| | | | |
| | | | |
**Family Psychiatric History:** _____________________________________________________
**Social History**
**Lives**: Single family House/Condo/ with stairs: ___________
**Marital Status**:________
**Education**:____________________________
**Employment Status**: ______
**Current/Previous occupation type**: _________________
**Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________
**Sexual Orientation:** _______ Sexual Activity: ____
**Contraception Use**: ____________
**Family Composition:** Family/Mother/Father/Alone
**: _____________________________**
**Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________**
**\_\_\______________________________________________________________________**
**Health Maintenance**
**Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia**
**Exposures:**
**Immunization HX:**
**Review of Systems (at least 3 areas per system):**
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
**Physical Exam**
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
**percentile**) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
**Mental Status Exam**
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
| |
| — |
| **Psychotherapy Note** |
| **Therapeutic Technique Used:** |
| **Session Focus and Theme:** |
| **Intervention Strategies Implemented:** |
| **Evidence of Patient Response**: |
**Plan:**
**Differential Diagnoses**
**1.**
**2.**
**Principal Diagnoses**
**1.**
**2.**
**Plan:**
**Diagnosis #1**
**Diagnostic Testing/Screening:**
**Pharmacological Treatment:**
**Non-Pharmacological Treatment:**
**Patient/Family Education:**
**Referrals:**
**Follow-up:**
**Anticipatory Guidance:**
**Diagnosis #2**
**Diagnostic Testing/Screening Tool:**
**Pharmacological Treatment:**
**Non-Pharmacological Treatment:**
**Patient/Family Education:**
**Referrals:**
**Follow-up:**
**Anticipatory Guidance:**
**Signature (with appropriate credentials): __________________________________________**
**Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________**
**DEA#: 101010101 STU Clinic LIC# 10000000**
**Tel: (000) 555-1234 FAX: (000) 555-12222**
Patient Name: (Initials)______________________________ Age ___________
Date: _______________
**RX ______________________________________**
**SIG:**
**Dispense**: ___________
**Refill:** _________________
**No Substitution**
**Signature:** ____________________________________________________________
**Rev. 2272022 LM**
**## soapnoteinstructions.docx**
Comprehensive Psychotherapy Evaluation 1
1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
2. OAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
| | |
| — | — |
| **S =** | Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS) |
| **O =** | Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam |
| **A =** | Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes |
| **P =** | Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up |
**Make it sure it is psychotherapy on a patient with anxiety/depression**
**## soapnoteetemplate.docx**
**Comprehensive Psychiatric Evaluation Template**
**With Psychotherapy Note**
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
**HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
**SI/HI:** _______________________________________________________________________________
**Sleep:**_________________________________________
**Appetite:**\_\_\______________________
**Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________
**Current perception of Health**: Excellent Good Fair Poor
**Psychiatric History:**
**_Inpatient hospitalizations:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_Outpatient psychiatric treatment:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_Detox/Inpatient substance treatment:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_History of suicide attempts and/or self injurious behaviors:_**\_\_\__________________________________
**Past Medical History**
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
**Past Surgical History**\_\_\_________________________________________________________
**_Current psychotropic medications:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_Current prescription medications:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_OTC/Nutritionals/Herbal/Complementary therapy:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_Substance use_** _:_(alcohol, marijuana, cocaine, caffeine, cigarettes)
| | | | |
| — | — | — | — |
| **_Substance_** | **_Amount_** | **_Frequency_** | **_Length of Use_** |
| | | | |
| | | | |
| | | | |
| | | | |
**Family Psychiatric History:** _____________________________________________________
**Social History**
**Lives**: Single family House/Condo/ with stairs: ___________
**Marital Status**:________
**Education**:____________________________
**Employment Status**: ______
**Current/Previous occupation type**: _________________
**Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________
**Sexual Orientation:** _______ Sexual Activity: ____
**Contraception Use**: ____________
**Family Composition:** Family/Mother/Father/Alone
**: _____________________________**
**Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________**
**\_\_\______________________________________________________________________**
**Health Maintenance**
**Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia**
**Exposures:**
**Immunization HX:**
**Review of Systems (at least 3 areas per system):**
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
**Physical Exam**
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
**percentile**) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
**Mental Status Exam**
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
| |
| — |
| **Psychotherapy Note** |
| **Therapeutic Technique Used:** |
| **Session Focus and Theme:** |
| **Intervention Strategies Implemented:** |
| **Evidence of Patient Response**: |
**Plan:**
**Differential Diagnoses**
**1.**
**2.**
**Principal Diagnoses**
**1.**
**2.**
**Plan:**
**Diagnosis #1**
**Diagnostic Testing/Screening:**
**Pharmacological Treatment:**
**Non-Pharmacological Treatment:**
**Patient/Family Education:**
**Referrals:**
**Follow-up:**
**Anticipatory Guidance:**
**Diagnosis #2**
**Diagnostic Testing/Screening Tool:**
**Pharmacological Treatment:**
**Non-Pharmacological Treatment:**
**Patient/Family Education:**
**Referrals:**
**Follow-up:**
**Anticipatory Guidance:**
**Signature (with appropriate credentials): __________________________________________**
**Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________**
**DEA#: 101010101 STU Clinic LIC# 10000000**
**Tel: (000) 555-1234 FAX: (000) 555-12222**
Patient Name: (Initials)______________________________ Age ___________
Date: _______________
**RX ______________________________________**
**SIG:**
**Dispense**: ___________
**Refill:** _________________
**No Substitution**
**Signature:** ____________________________________________________________
**Rev. 2272022 LM**
**## soapnoteinstructions.docx**
Comprehensive Psychotherapy Evaluation 1
1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
2. OAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
| | |
| — | — |
| **S =** | Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS) |
| **O =** | Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam |
| **A =** | Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes |
| **P =** | Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up |
**Make it sure it is psychotherapy on a patient with anxiety/depression**
**## soapnoteetemplate.docx**
**Comprehensive Psychiatric Evaluation Template**
**With Psychotherapy Note**
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
**HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
**SI/HI:** _______________________________________________________________________________
**Sleep:**_________________________________________
**Appetite:**\_\_\______________________
**Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________
**Current perception of Health**: Excellent Good Fair Poor
**Psychiatric History:**
**_Inpatient hospitalizations:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_Outpatient psychiatric treatment:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_Detox/Inpatient substance treatment:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_History of suicide attempts and/or self injurious behaviors:_**\_\_\__________________________________
**Past Medical History**
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
**Past Surgical History**\_\_\_________________________________________________________
**_Current psychotropic medications:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_Current prescription medications:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_OTC/Nutritionals/Herbal/Complementary therapy:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_Substance use_** _:_(alcohol, marijuana, cocaine, caffeine, cigarettes)
| | | | |
| — | — | — | — |
| **_Substance_** | **_Amount_** | **_Frequency_** | **_Length of Use_** |
| | | | |
| | | | |
| | | | |
| | | | |
**Family Psychiatric History:** _____________________________________________________
**Social History**
**Lives**: Single family House/Condo/ with stairs: ___________
**Marital Status**:________
**Education**:____________________________
**Employment Status**: ______
**Current/Previous occupation type**: _________________
**Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________
**Sexual Orientation:** _______ Sexual Activity: ____
**Contraception Use**: ____________
**Family Composition:** Family/Mother/Father/Alone
**: _____________________________**
**Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________**
**\_\_\______________________________________________________________________**
**Health Maintenance**
**Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia**
**Exposures:**
**Immunization HX:**
**Review of Systems (at least 3 areas per system):**
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
**Physical Exam**
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
**percentile**) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
**Mental Status Exam**
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
| |
| — |
| **Psychotherapy Note** |
| **Therapeutic Technique Used:** |
| **Session Focus and Theme:** |
| **Intervention Strategies Implemented:** |
| **Evidence of Patient Response**: |
**Plan:**
**Differential Diagnoses**
**1.**
**2.**
**Principal Diagnoses**
**1.**
**2.**
**Plan:**
**Diagnosis #1**
**Diagnostic Testing/Screening:**
**Pharmacological Treatment:**
**Non-Pharmacological Treatment:**
**Patient/Family Education:**
**Referrals:**
**Follow-up:**
**Anticipatory Guidance:**
**Diagnosis #2**
**Diagnostic Testing/Screening Tool:**
**Pharmacological Treatment:**
**Non-Pharmacological Treatment:**
**Patient/Family Education:**
**Referrals:**
**Follow-up:**
**Anticipatory Guidance:**
**Signature (with appropriate credentials): __________________________________________**
**Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________**
**DEA#: 101010101 STU Clinic LIC# 10000000**
**Tel: (000) 555-1234 FAX: (000) 555-12222**
Patient Name: (Initials)______________________________ Age ___________
Date: _______________
**RX ______________________________________**
**SIG:**
**Dispense**: ___________
**Refill:** _________________
**No Substitution**
**Signature:** ____________________________________________________________
**Rev. 2272022 LM**
– 1
– 2