initial evaluation/management (e/m) assessment part 1...

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


(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


(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:


(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


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:


(E/M) Assessment

Social History (SH) Non-Contributory? □ Non-contributory


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


(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


□ Ulcers

Symptoms: □ Burning

□ Dryness

□ Redness Exceptions Noted

□ Reviewed: No □ Vision ChangesComplaints Unless

6/14


(E/M) Assessment

Exceptions/Notes: I

Symptoms: □ Constipation

□ Dysphagia

□ Nausea/Heartburn

Exceptions/Notes:

Symptoms: □ Abnormal Menses

□ Breast Changes

□ Discharge

□ Dysuria

Exceptions/Notes:

GI □ Pain


□ 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


□ Sexual Changes

□ Urinary Retention



□ 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


(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


□ Sputum

□ Wheezing

□ Shortness of Breath

Exceptions/Notes:

Skin Symptoms: □ Diaphoresis

□ Lesion

□ Pruritus

□ Rash


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


(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:


(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


(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


(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


(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


(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

initial evaluation/management (e/m) assessment part 1...

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