Submit a psychiatric progress note in the discussion board. You must use an actual patient from your clinical, but remove all identifying information (names, places, etc.) so that it is HIPAA compliant.

You may use the format below for your note, or the format you use at your clinical site.
Psychiatric Patient Progress Note

Demographic data: Do not include identifying information. Must be HIPAA compliant.

Chief complaint:

History of present illness:

Current working diagnoses:

Current psychiatric medications:

Non-psychiatric medications:

Allergies:

Review of Systems: As appropriate, listed by body systems in bullet form

Mental Status Exam:

Physical Exam: 

Physical exams should be appropriate for the patient and your clinical setting (inpatient acute psychiatric facility). For example: a telehealth follow up for MDD versus an inpatient psychiatric unit for acute psychosis will have different physical exams.

VS: If obtained

Results: If applicable and results obtained

PHQ9: HAM-A

Labs:

Impression: Narrative discussion of current status and symptoms, how the patient is tolerating the current treatment and any progress toward goals. Also discuss any change in diagnoses or changes to the plan and the reason why. Always discuss the safety evaluation and current safety plan.

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