initial evaluation/management (e/m) assessment part 1...
TRANSCRIPT
Client:
Staff:
Summit Psychological Associates, Inc. - Initial Evaluation/Management
(E/M) Assessment
Session Information
Document Date: Client Program:
Initial Evaluation/Management (E/M) Assessment Part 1 - Chief Complaint and History - SPA.5
Summit Psychological Associates, Inc.
Evalution/Management (E/M) Progress Note Is Client: 0 Consultation O Established Patient
DOB:
Age:
Gender/Gender Expression: Female Client's Race: □ Alaskan Native
□ Asian□ Black/African American
Marital Status: Common Law 0 Divorced 0 Married
(seen within past 3 New Patient (not seen
within past 3 years) years)
0 Male O Other D Native American D Other □ Native Hawaiian/Other □ White
Pacific Islander
0 Other 0 Separated
Present at Session: 0 Client Not Present; 0 Client Plus Other(s)
0 Single OWidowed
Client Present by himself/herself Other(s) Present (e.g. Present
parent present without child)
Referral Source:
Chief Complaint: Concise statement that describes the symptom, problem, condition, diagnosis, and reason for patient encounter, usually in patient's own words
Is client presenting for Yes treatment for opiate O No dependence?
Age of first use of opiates:
Peak use of opiates (number of times per
day): Longest period of
abstinence: Last use of opiates:
Cravings? 0 N/A Withdrawal Symptoms: □ Anxiety
□ Appetite□ Delusions□ Depression
No □Guilt□ Hallucinations□ Nightmares□ None Reported
HISTORY TYPE
I Requirements for Levels of History
OYes □ Pain□ Sleep□ Weight changes
o
o
o
o
o
o
1/14
Summit Psychological Associates, Inc. - Initial Evaluation/Management
(E/M) Assessment
1. PROBLEM FOCUSED LEVEL OF HISTORY requires: Brief History of PresentIllness (HPI) and no Past, Family, Social History (PFSH)
2. EXPANDED PROBLEM FOCUSED LEVEL OF HISTORY requires: BriefHistory of Present Illness (HPI) and no Past, Family, Social History (PFSH)
3. DETAILED LEVEL OF HISTORY requires Extended History of Present Illness(HPI) and Pertinent Past, Family, Social History (PFSH)
4. COMPREHENSIVE LEVEL OF HISTORY requires Extended History ofPresent Illness (HPI) and Complete Past, Family, Social History (PFSH)
History Type - select O 1. Problem Focused O 3. Detailed 4. Comprehensiveone:
0 2. Expanded Problem Focused
History of Present Illness (HPI) History of Present O Existing Problem New Problem
Illness (HPI):
1. Brief History of Present Illness (HPI) requires 1-3 Elements
2. Extended History of Present Illness (HPI) requires 4+ Elements or 3+ chronic/inactive conditions
For Extended History of Present Illness (HPI),
select 4+ Elements or 3+ chronic/inactive
conditions:
Location:
Select 3 or 4, accordingly □ Associated Signs and
Symptoms
□ Context
□ Duration
Quality:
Severity:
Duration:
Timings:
Context:
Modifying Factors:
□ Location
□ Modifying Factors
□ Quality
□ Severity
□ Timings
Current Meds (include For each medication, list medication name, rationale, dosage/route/frequency and medical, psychiatric, compliance (Yes, No, Partial, Unknown). Comment on Any Side Effects to
OTC/herbal medications): Medications)
Medication compliance? 0 No
Partial
Medication(s):
Side Effects: □ Akasthisia
□ Appetite Changes
□ Constipation
□ Diaphoresis
□ Dilated Pupils
□ Dizziness
□ Drowsiness
□ Headaches
□ Hypersomnia
Abnormal Involuntary O Needs Update Movement Scale (AIMS)
Check: No Update Needed
0 Unknown OYes
□ Insomnia □ Thirst/Dry Mouth
□ Movements (involuntary) □ Tremors
D Muscle Aches/Cramps □ Urinary Frequency
□ Nausea/Heartburn □ Urinary Retention
□ None Reported □ Vision Changes
□ Other □ Vomiting
□ Seizures □ Weight Gain
□ Sexual Changes □ Weight Loss
□ Skin Rash
0 Not Applicable 0 Updated This Date (*answer
following AIMS questions)
o
o
oEffectiveness of
o2/14
Summit Psychological Associates, Inc. - Initial Evaluation/Management
(E/M) Assessment
AIMS: Muscles of Facial Expression: o Blinking o Grimacing o Movements of Cheekso Movements of Eyebrows o Movements of Forehead
o Movements of Periorbital o Smiling
AIMS: Lips and Perioral Area: o Pouting o Puckering o Smacking
AIMS: Jaw: o Biting o Chewing o Clenching o Lateral Movement o Mouth opening
AIMS: Tongue (Rate only if increase in movement in and out, NOT inability to sustain movement): o Yes o No
AIMS: Upper (Arms, Wrists, Hands, Fingers): (Choreic or athetoid movements; do NOT include tremor (repetitve, regular, rhythmic) o Yes o No
AIMS: Lower (Legs, Knees, Ankles, Toes): o Eversion of foot o Foot squirming o Foot tappingo Heel dropping o Inversion of foot o Lateral knee movement
AIMS: Neck, Shoulders, Hips: o Pelvic Gyrations o Rocking o Squirming o Twisting
AIMS: Severity of Abnormal Movements:
AIMS: Incapacitation Due to Abnormal Movements:
AIMS: Client Awareness of Abnormal Movements:
AIMS: Current Problems with Teeth and/or Dentures: o Yes o No
AIMS: Does Client Usually Wear Dentures? o Yes o No
3/14
Issues related to medication dosages:
Adverse Drug Reaction/ Allergies:
Summit Psychological Associates, Inc. - Initial Evaluation/Management
(E/M) Assessment
Pregnancy/Lactation Status: Check all that apply □ Lactating □ Not lactating
□ N/A □ Not pregnant
□ Pregnant
Past, Family, Social History (PFSH) 1. Pertinent PFSH = 1 specific item from EITHER Past, Family OR Social History
2. Complete PFSH for New Patient: 1 specific item from Past , Family, AND SocialHistory
3. Complete PFSH for Established Patient: 1 specific item from 2/3 of hx areas(Past, Family, Social)
Complete PFSH for New □ OKPatient requires 1
specific item from Past, Family, AND Social
History:
Family History (FH) Non-Contributory?
No Interval Change Since:
Family Psychiatric/AoD History:
□ Non-contributory
□ ADD
□ Anxiety Disorder
□ Bipolar Disorder
Medical problems in □ Cancernuclear family:
0 Diabetes
Mother: □ Deceased
Cause of mother's death:
Father: □ Deceased
Cause of father's death:
Siblings: Number living:
Siblings: Number deceased:
Cause of siblings' deaths:
□ Depression
□ Other
□ Heart Disease
□ Hyperlipidemia
0 Living
0 Living
Past History (PH) Non-Contributory? □ Non-contributory
No Interval Change Since:
Past Psychiatric Hospitalizations -
Include name(s) of hospital(s), date(s) and
reason(s):
Past Psychiatric Outpatient Treatment -Include name of each
agency, date(s) and reason(s):
Surgeries:
□ Schizophrenia
□ Substance Abuse
□ Hypertension
□ Other
4/14
lllness(es): Injuries:
Immunizations:
Summit Psychological Associates, Inc. - Initial Evaluation/Management
(E/M) Assessment
Social History (SH) Non-Contributory? □ Non-contributory
No Interval Change Since:
AoD Use History (include tobacco use):
AoD Treatment History:
Born/Raised in: Raised by: Education:
Any history of abuse, exposure to domestic
violence, birth trauma, developmental trauma,
etc. Legal History:
Employment/Military History:
Marital/Relationship History:
Initial Evaluation/Management (E/M) Assessment Part 2 - Review of Systems- SPA.3
History Type - must O 1. Problem Focused O 3. Detailed □ 4. Comprehensivemake same selection as
on Part 1 of this Initial O 2. Expanded Problem
E/M Assessment: Focused
Requirements for Levels of History
1. PROBLEM FOCUSED LEVEL OF HISTORY requires NO Review of Systems(ROS)
2. EXPANDED PROBLEM FOCUSED LEVEL OF HISTORY requires ProblemPertinent Review of Systems (ROS)
3. DETAILED LEVEL OF HISTORY requires Extended Review of Systems (ROS)
4. COMPREHENSIVE LEVEL OF HISTORY requires Complete Review ofSystems (ROS)
Complete ROS requires Select at least 10 Systems to review
□ NeurologicalPositive and Pertinent □ Allergic/lmmunoNegative Responses for at least 10 Systems: □ Cardio-Vascular
□ Eyes
□ GI
□ GU/GYN
□ Psychiatric
□ Respiratory□ Constitutional
□ ENT/Mouth
□ Endocrinology
□ Hematologic/Lymphatics □ Skin
□ Musculoskeletal
Review of Systems (ROS)
Those Systems with Positive or Pertinent Negative Responses Must Be Individually Documented
5/14
Summit Psychological Associates, Inc. - Initial Evaluation/Management
(E/M) Assessment
Allergic/lmmuno □ Hives □ Medication AllergiesSymptoms: □ Asthma
□ Eczema D Immunologic Deficiency □ Reviewed: No Complaints Unless Exceptions Noted
Exceptions/Notes:
Cardio-Vascular Symptoms: □ Bleeding □ Edema
□ Bruising □ Palpitations
□ Chest Pain
Exceptions/Notes:
Constitutional Symptoms: □ Fatigue □ Insomnia
Exceptions/Notes:
□ Gait Disturbance □ Reviewed: NoComplaints UnlessExceptions Noted
Endocrinology Symptoms: □ Hyperglycemia □ Polydipsia
Exceptions/Notes:
□ Hypoglycemia D Polyuria
ENT/Mouth Symptoms: □ Headache □ Sinusitis
Exceptions/Notes:
□ Reviewed: NoComplaints UnlessExceptions Noted
□ Tinnitus
Eyes
D Reviewed: No Complaints Unless Exceptions Noted
□ Syncope
□ Skin Rash
□ Reviewed: NoComplaints UnlessExceptions Noted
□ Ulcers
Symptoms: □ Burning
□ Dryness
□ Redness Exceptions Noted
□ Reviewed: No □ Vision ChangesComplaints Unless
6/14
Summit Psychological Associates, Inc. - Initial Evaluation/Management
(E/M) Assessment
Exceptions/Notes: I
Symptoms: □ Constipation
□ Dysphagia
□ Nausea/Heartburn
Exceptions/Notes:
Symptoms: □ Abnormal Menses
□ Breast Changes
□ Discharge
□ Dysuria
Exceptions/Notes:
GI □ Pain
□ Reviewed: NoComplaints UnlessExceptions Noted
□ Vomiting
GU/GYN □ Hematuria
□ Incontinence
□ Lactating
□ Pregnant
Hematologic/Lymphatics Symptoms: □ Adenopathy □ Bleeding
□ Anemia
Exceptions/Notes:
Symptoms: □ Cramps
□ Falls
Rate pain on 0-10 Pain Scale:
Exceptions/Notes:
Symptoms: □ Akathisia
□ Aphasia
□ Bruises
Musculoskeletal □ Muscle Aches
□ Pain
Neurological □ Drowsiness
□ Headaches
□ Weight Gain
□ Weight Loss
□ Reviewed: NoComplaints UnlessExceptions Noted
□ Sexual Changes
□ Urinary Retention
□ Reviewed: NoComplaints UnlessExceptions Noted
□ Reviewed: NoComplaints UnlessExceptions Noted
□ Twitching
□ Seizures
□ Tardive dyskinesia
□ Ataxia □ Movements (involuntary) □ Tremors
□ Confusion
□ Dilated Pupils
□ Dizziness
□ Pseudo-parkinsonism □ Vision Changes
□ Reviewed: No □ WeaknessComplaints UnlessExceptions Noted
7/14
Exceptions/Notes: I
Summit Psychological Associates, Inc. - Initial Evaluation/Management
(E/M) Assessment
Psychiatric Symptoms: □ History of Anxiety □ History of □ History of Psychosis
Exceptions/Notes:
□ History of DepressionDevelopmental Disability
□ Reviewed: No□ History of Personality Complaints Unless
Disorder Exceptions Noted
Respiratory Symptoms: □ Congestion
□ Cough
□ Reviewed: NoComplaints UnlessExceptions Noted
□ Sputum
□ Wheezing
□ Shortness of Breath
Exceptions/Notes:
Skin Symptoms: □ Diaphoresis
□ Lesion
□ Pruritus
□ Rash
□ Reviewed: NoComplaints UnlessExceptions Noted
Exceptions/Notes:
Initial Evaluation/Management (E/M) Assessment Part 3 - Exam TypeSPA.4
Does patient have □ YesMedicare? 0 No
Examination
EXAM TYPE EXAM TYPE
CONTENT AND DOCUMENTATION REQUIREMENTS
1. PROBLEM FOCUSED LEVEL OF EXAM: Perform and document 1-5 elementsidentified by an asterisk (*)
2. EXPANDED PROBLEM FOCUSED LEVEL OF EXAM: Perform and documentat least 6 elements defined by an asterisk (*)
3. DETAILED LEVEL OF EXAM: Perform and document at least 9 elementsidentified by an asterisk (*)
4. COM PREHENSIVE LEVEL OF EXAM: Perform ALL elements identified by anasterisk(*) in the Constitutional, Musculoskeletal and Psychiatric sections; plus atleast one element of every other section
Exam Type - select one: 0 1. Problem Focused O 2. Expanded Problem Focused
8/14
Summit Psychological Associates, Inc. - Initial Evaluation/Management
(E/M) Assessment
I O 3. Detailed □ 4. Comprehensive
1. CONSTITUTIONAL
* Measurements of ANY □ HeightTHREE OF THE
FOLLOWING 7 VITAL □ Pulse
SIGNS: □ Respiration Height:
Weight:
Sitting or Standing Blood Pressure:
Supine Blood Pressure:
Pulse:
Temperature:
Respiration:
□ Sitting or StandingBlood Pressure
□ Supine Blood Pressure
□ Temperature□ Weight
BMI (Required for Calculate BMI at website: http://www.nhlbi.nih.gov/health/educational/lose_wt/ patients with BMl/bmicalc.htm
Mediicare):
* General Appearance: □ Disheveled□ No deformities□ Normal habitus
□ Unkempt□ Well developed
2. PSYCHIATRIC* Description of speech: Check all that apply
□ Abnormal rate□ Abnormal volume□ Clear□ Difficulty with
articulation
□ Incoherence□ Lack of spontaneity□ Normal
Describe any abnormalities of
(e.g. perseveration, paucity of language)
speech:
* Description of thoughtprocesses:
Check all that apply □ Abnormal rate of
thoughts □ Abnormal thought
content
□ Illogical□ Logical□ Normal
□ Computation difficultiesDescribe any
abnormalities with thought processes:
* Description ofassociations:
Describe any abnormalities with
associations: * Description of
abnormal or psychotic thoughts:
Check all that apply □ Circumstantial□ Intact
□ Delusions□ Hallucinations□ Homicidal ideation
Describe abnormal or psychotic thoughts:
* Description of
□ Loose
□ Normal□ Obsessions
□ Well groomed□ Well nourished
□ Pressured□ Rapid
□ Slurred
□ Problems with abstractreasoning
□ Racing thoughts□ Tangential
□ Tangential
□ Preoccupation withviolence
□ Suicidal ideation
9/14
judgment (of everyday activities & social
situations) and insight:
Summit Psychological Associates, Inc. - Initial Evaluation/Management
(E/M) Assessment
Complete Mental Status Examination *Orientation: Check all that apply
□ Not Oriented □ Oriented to Place □ Oriented to Time
□ Oriented to Person □ Oriented to Situation
*Recent and RemoteMemory: □ Problem with recent □ Problem with remote
memory memory
* Attention Span and
Check all that apply □ No memory problems
noted
Check all that apply Concentration: □ Impaired attention span □ Normal attention span □ Normal concentration
□ Impaired concentration
*Language (e.g. namingobjects, repeating
phrases): *Fund of Knowledge (e.g. awareness of current
events, past history,vocabulary):
*Mood and Affect: Check all that apply □ Agitation
Additional Problems (e. g. sleep, appetite, eating
disorder, obsessions,compulsions):
Comments:
□ Angry
□ Anxiety
□ Constricted affect
□ Depression
□ Euthymic
□ Flat affect
□ Full affect
□ Guarded
□ Hypomania
3.MUSCULOSKELETAL
□ Inappropriate affect
□ Irritable
□ Lability
□ Other problem
*Assessment of muscle (e.g. flaccid, cog wheel, spastic) with notation of any atrophy and abnormalstrength and tone: movements
* Examination of gaitand station:
Findings: I
Findings: I
4. NEUROLOGICAL
5. Head and Face
6.Eyes
7. Ears, Nose, Mouth and Throat Findings: I
8.NeckFindings: I
10/14
Summit Psychological Associates, Inc. - Initial Evaluation/Management
(E/M) Assessment
9. RespiratoryFindings: I
10. CardiovascularFindings: I
11. Chest (Breasts)Findings: I
12. Gastrointestinal (Abdomen)Findings: I
13. GenitourinaryFindings: I
14. LymphaticFindings: I
15. ExtremetiesFindings: I
16. SkinFindings: I
Initial Evaluation/Management (E/M) Assessment Part 4-Tx Recs, Interventions, MOM - SPA.7
MEDICAL DECISION MAKING (MOM) TYPE
Medical Decision Making (MDM) Type -
select one:
Was an OARRS Check Needed today?
To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded.
1. STRAIGHTFORWARD DECISION MAKING requires 2 of 3:A. MINIMAL Number of diagnoses or management optionsB. MINIMAL OR NONE for Amount and/or complexity of data to be reviewedC. MINIMAL Risk of complications and/or morbidity or mortality
2. LOW COMPLEXITY DECISION MAKING requires 2 of 3:A. LIMITED Number of diagnoses or management optionsB. LIMITED for Amount and/or complexity of data to be reviewedC. LOW Risk of complications and/or morbidity or mortality
3. MODERATE COMPLEXITY DECISION MAKING requires 2 of 3:A. MULTIPLE Number of diagnoses or management optionsB. MODERATE for Amount and/or complexity of data to be reviewedC. MODERATE Risk of complications and/or morbidity or mortality
4. HIGH COMPLEXITY DECISION MAKING requires 2 of 3:A. EXTENSIVE Number of diagnoses or management optionsB. EXTENSIVE for Amount and/or complexity of data to be reviewedC. HIGH Risk of complications and/or morbidity or mortality
0 1. Straightforward
0 2. Low Complexity
0 3. Moderate Complexity □ 4. High Complexity
The Ohio Automated Rx Reporting System (OARRS) is a tool to track the dispensing and personal furnishing of controlled prescription drugs to patients.
□ Yes□ No
11/14
Summit Psychological Associates, Inc. - Initial Evaluation/Management
(E/M) Assessment
Specify any irregularities found or
write "No irregularities": Comments:
Therapeutic Intervention (s) Provided:
Therapeutic Interventions Provided Check all that apply □ Change in Medication D Naltrexone 50 mg
(s) tablets q d #30
□ Continue currentmedication(s)
□ Other
□ Other psychotropic□ Encouraged abstinence medications
and compiance
□ Medication monitoring
□ Provided support
□ Symptom review
□ Vivitrol 380 mg IM
Counseling and Coordination of Care Provided
Counseling Provided to Client/Family Regarding:
Check all that apply
□ Client/Family/CaregiverEducation
Level of Care Recommended:
Indicated Services Recommendations:
Summary of Key Laboratory Results
(Include whether results were shared with
client):
□ Diagnostic Results/Impressions and/orRecommended MedicalStudies
□ Explained rationale,
□ Followup Plan due toBMI Outside of NormalParameters
□ Instructions forManaging Treatment and/or Follow Up
□ Potential drug-druginteractions and/or drug-allergy interactions, ifapplicable
□ Other
benefits, risks andtreatment alternativesto/for client
□ 1 - Non-IntensiveOutpatient Treatment
Check all that apply □ Case Management/
Community PsychiatricSupport Treatment(CPST) Services
□ Group OutpatientCounseling
□ 2 - IOP (IntensiveOutpatient Treatment)
□ Individual OutpatientCounseling
□ Med/Som
Review of Records: Check all that apply and specify below
□ Risk Factors and Planfor Reduction
□ Risk Factors ofmedication related topregnancy, if applicable
□ Risks and Benefits ofTreatment Options
□ 3 - Other
□ Other
□ Psychiatry
□ Discussion of test □ Old records reviewed □ Previous Test resultsresults with otherphysician
□ History obtained fromother source
Medical Recommendations/ Instructions:
Laboratory Tests Ordered:
Followup Plan:
Other Considerations to Or put "None indicated at this time" be Added for Non-
Pharmacological Services in Treatment Plan:
Client/Guardian Response Check all that apply
12/14
Summit Psychological Associates, Inc. - Initial Evaluation/Management
(E/M) Assessment
to Recommendations: □ Client agrees withmedication
Coordination of Care Provided (coordinate
with care provider outside agency w/client
present)? Coordination of Care
completed with:
□ Client does notunderstand
□ Client refusesmedication
□ Yes
ONo
Check all that apply □ Caregiver
□ Family
Minutes spent providing Counseling and/or
Coordination of Care during appointment:
Was more than 50% of □ Yespt. face to face time
O Nospent providing counseling and/or
coordination of care? Follow up Visit: □ 1 Month
□ Client understands □ ParenUGuardian refusesinformation medication
D ParenUGuardian agrees D ParenUGuardian under-with medication stands information
□ ParenUGuardian doesnot understand
□ Other □ Probation/Parole
□ PCP/Outside Medical □ SchoolStaff
0 3 Months 0 Other
Client DSM Diagnosis as of 9/13/2018 09:40 AM
Client:
Effective Date/Time: External Diagnosis: Diagnosed By: Comments:
DSM-5 Severity/Specifier
The Diagnoses above display in priority order.
Diagnosis ICD-10 Comments
Psychosocial and Contextual Factors ICD-10 Code - Description
Begin Date End Date
Comments
Diagnostic Formulation
Client Medications Amount/Refills Status
13/14
Summit Psychological Associates, Inc. - Initial Evaluation/Management
(E/M) Assessment
Interactive Complexity Determination - SPA.1
Interactive Complexity Determination
Interactive complexity refers to specific COMMUNICATION factors that complicate the delivery of a
psychiatric procedure and occur DURING the delivery of the service
Was at least one of the following communication factors present during the visit?
The need to manage maladaptive communic
ation, e.g. high reactivity/disagreement
among family members:
Explain:
Emotions or behavior by the caregiver that
impede implementation of the treatment plan:
Explain:
Mandated reporting such as in situations
involving abuse:
Explain:
T he need to manage maladaptive communication (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care. □ YesONo
Caregiver emotions or behaviors that interfere with implementation of the treatment plan. □ Yes
ONo
Evidence or disclosure of a sentinel event and mandated report to a third party (e.g., abuse or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with patient and other visit participants. □ Yes
ONo
Signatures
Signature #1: I
14/14