Assignment Criteria

Level III

Level II

Level I

Not Present

Criteria 1

Level III Max Points

Points: 8

Level II Max Points

Points: 6.4

Level I Max Points

Points: 4.8

0 Points

Subjective Information

· Complete and concise summary of pertinent information.

· Well organized; partial but accurate summary of pertinent information (>80%).

· Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “S” provided.

· Does not meet the criteria

Assignment Criteria

Level III

Level II

Level I

Not Present

Criteria 2

Level III Max Points

Points: 8

Level II Max Points

Points: 6.4

Level I Max Points

Points: 4.8

0 Points

Objective Information

· Complete and concise summary of pertinent information.

· Partial but accurate summary of pertinent information (>80%).

· Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “O” provided.

· Does not meet the criteria

Assignment Criteria

Level III

Level II

Level I

Not Present

Criteria 3

Level III Max Points

Points: 8

Level II Max Points

Points: 6.4

Level I Max Points

Points: 4.8

0 Points

Assessment: Problem Identification and Prioritization

· Complete problem list generated and rationally prioritized; no extraneous information or issues listed.

· Most problems are identified and rationally prioritized, including the “main” problem for the case (>80%).

· Some problems are identified (50%-80%); incomplete or inappropriate problem prioritization; includes nonexistent problems or extraneous information included.

· Does not meet the criteria

Criteria 4

Level III Max Points

Points: 8

Level II Max Points

Points: 6.4

Level I Max Points

Points: 4.8

0 Points

Assessment: Assessment of Current Psychiatric & Medical Condition(s) or Drug Therapy-related Problem

· An optimal and thorough assessment is present for each problem

· An assessment is present for each problem listed but not optimal

· Assessment is present for 50-80% of problems

· Does not meet the criteria

Assignment Criteria

Level III

Level II

Level I

Not Present

Criteria 5

Level III Max Points

Points: 6

Level II Max Points

Points: 4.8

Level I Max Points

Points: 3.6

0 Points

Assessment: Treatment Goals

· Appropriate and relevant therapeutic goals for each identified problem.

· Appropriate therapeutic goals for most identified problems (>80%).

· Appropriate therapeutic goals for a few identified problems (50%-80%).

· Less than 50% of problems have appropriate therapeutic goals.

Assignment Criteria

Level III

Level II

Level I

Not Present

Criteria 6

Level III Max Points

Points: 6

Level II Max Points

Points: 4.8

Level I Max Points

Points: 3.6

0 Points

Plan: Treatment Plan

· Specific, appropriate and justified recommendations (including drug name, strength, route, frequency, and duration of therapy) for each identified problem are included.

· Includes most of the requirements for each identified problem (>80%).

· Incomplete and/or inappropriate for a few identified problems (50%-80%); information other than “P” provided.

· Less than 50% of problems have an appropriate and complete treatment plan.

Criteria 7

Level III Max Points

Points: 6

Level II Max Points

Points: 4.8

Level I Max Points

Points: 3.6

0 Points

Plan: Counseling, Referral, Monitoring & Follow-up

· Specific patient education points, monitoring parameters, follow-up plan and (where applicable) referral plan for each identified problem.

· Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for >80% of identified problems.

· Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for a few identified problems (50%-80%).

· Less than 50% of problems include appropriate counseling, monitoring, referral and/or follow-up plan.

Maximum Total Points

50

40

30

Minimum Total Points

41 points minimum

31 points minimum

1 point minimum

Criteria

Clinical Notes

Informed Consent

Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion)

Subjective

Verify Patient

Name:

DOB:

Minor:

Accompanied by:

Demographic:

Gender Identifier Note:

CC:

HPI:

Pertinent history in record and from patient: X

During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.

Patient self-esteem appears fair, no reported feelings of excessive guilt,

no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy,

no reported changes in concentration or memory.

Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks.

Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature.

SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors.

Allergies: NKDFA.

(medication & food)

Past Medical Hx:

Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.

Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.

Surgical history no surgical history reported

If Minor obtain Developmental Hx: (most often from parents), in utero, birth and delivery hx, early childhood, school hx, behavior, etc…

Nutritional status (this is an important component to gauge how well the mind and body are being nourished for full function. Ex: lack of iodine create thyroid issues, thyroid issues creates metabolism issues which affects function of cognition, mood, etc…)

Past Psychiatric Hx:

Previous psychiatric diagnoses: none reported.

Describes stable course of illness.

Previous medication trials: none reported.

Safety concerns:

History of Violence to Self: none reported

History of Violence t o Others: none reported

Auditory Hallucinations:

Visual Hallucinations:

Mental health treatment history discussed:

History of outpatient treatment: not reported

Previous psychiatric hospitalizations: not reported

Prior substance abuse treatment: not reported

Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events.

Substance Use: Client denies use or dependence on nicotine/tobacco products.

Client does not report abuse of or dependence on ETOH, and other illicit drugs.

Current Medications: No current medications.

(Contraceptives):

Supplements:

Past Psych Med Trials:

Family Medical Hx:

Family Psychiatric Hx:

Substance use

Suicides

Psychiatric diagnoses/hospitalization

Developmental diagnoses

Social History:

Occupational History: currently unemployed. Denies previous occupational hx

Military service History: Denies previous military hx.

Education history: completed HS and vocational certificate

Developmental History: no significant details reported.

(Childhood History)

Legal History: no reported/known legal issues, no reported/known conservator or guardian.

Spiritual/Cultural Considerations: none reported.

ROS:

Constitutional: No report of fever or weight loss.

Eyes: No report of acute vision changes or eye pain.

ENT: No report of hearing changes or difficulty swallowing.

Cardiac: No report of chest pain, edema or orthopnea.

Respiratory: Denies dyspnea, cough or wheeze.

GI: No report of abdominal pain.

GU: No report of dysuria or hematuria.

Musculoskeletal: No report of joint pain or swelling.

Skin: No report of rash, lesion, abrasions.

Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia.

Hematologic: No report of blood clots or easy bleeding.

Allergy: No report of hives or allergic reaction.

Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)

Verify Patient: Name, Assigned  identification number (e.g., medical record number), Date of birth, Phone number