Please complete the form below
    1. INTERIM HISTORY Document an interval history of client including progress made since last session, effectiveness of medications, progress related to symptoms, substance use, significant new issues, changes in family and social history and overall functioning. MENTAL STATUS Comment on current areas of mental status evaluation, including significant changes since the last visit. Document any risk issues and if present, document action plan to address. MEDICATION ADMINISTRATION Client takes meds as prescribed. Record whether the medication was taken as prescribed since last session, yes/no. Provide additional relevant information after response. YesNoNot Applicable SIDE EFFECTS Record whether side effects are present or occurred since the last session, yes/no or n/a. Provide additional relevant information after response, e.g. increased thirst, dizziness, decreased sexual function. YesNoNot Applicable ALLERGIC REACTIONS Record any reported or observed allergic reactions to medications. As appropriate, provide additional relevant information. CHANGES IN MEDICAL STATUS Record whether there have been any changes in medical status since the last session, yes/no or n/a. Provide additional relevant information after response. YesNoNot Applicable OTHER MEDICATIONS Record any other medications the person is/was taking since last session, over the counter/herbal/ none/other. Provide additional relevant information after response. YesNoNot Applicable GOAL(S) ADDRESSED AS PER PSYCHOPHARMACOLOGY PLAN Identify the specific goal(s) and objectives in the Psychopharmacology Plan or IAP being addressed during this intervention. THERAPEUTIC INTERVENTIONS DELIVERED IN SESSION
    2. Psychotherapy Counseling/Coaching Collaborative Medication ManagementCollaborative Medication Education/Symptom/Illness ManagementInjectionsPhysical Assessment Coordination of Care
    3. Provide additional relevant information as appropriate. LAB TESTS ORDERED Summarize key laboratory test results received and reviewed. Indicate whether key laboratory test results were ordered or, reviewed (with the client). If lab results were not received, describe the action to be taken to obtain results. AIMS FINDINGS If AIMS (Abnormal Involuntary Movement Scale) test was administered, document findings. HEIGHT/WEIGHT/BMI BLOOD PRESSURE / VS Record information pertaining to client's height, weight, body mass index, blood pressure, and vital signs as relevant. Provide additional relevant information as appropriate. DIAGNOSIS Document whether the person’s diagnosis has changed or not. RATIONALE FOR CHANGES IN MEDICATIONS Document rationale for any medication changes or for leaving medications as is. For each medication prescribed, indicate if the medication is renewed (renew) newly prescribed (new) or discontinued (d/c). Write the name of the medication (med), dosage (dose), frequency (frequency), # of Days, quantity (qty), and the number of refills (refills) prescribed. For each new medication prescribed, the person should be given information about medication risks and benefits. Indicate whether the client has given “informed consent”, i.e. demonstrated an understanding of medication’s risks and benefits. INSTRUCTIONS / COMMENTS AS APPLICABLE Document any additional relevant instructions or psycho-educational information. CLIENT ACCEPTANCE OF TREATMENT ASSESSMENT (if applicable) YesNo HMA PROVIDER NAME HMA PROVIDER SPECIALITY NEXT APPOINTMENT WITH CLIENT DATA ENTRY DATE By submitting this form, the provider acknowledges all information provided was at the consent of the client (family) and caregiver & intended solely for treatment purposes.

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