Provider: CPT codes:

Patients Name: _____________________________________________ Date of Visit and Time:________________________

Interval History:
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Interval Psychiatric Assessment/ Mental Status Examination:
Appearance/Behavior
Speech
Mood/Affect
SI.. HI
Thought Process
Thought Content...
Hallucinations.
Cognitive Functioning Insight & Judgment.

Current Diagnosis: ___________________________________________________________________________

Diagnosis Update: ____________________________________________________________________________
Current Medication(s)/Medication Change(s) including SE description:
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Lab Tests (ordered or reviewed) comments:
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Counseling Provided with Patient / Family / Caregiver (circle as appropriate and check off each counseling topic discussed
and describe below:
Diagnostic results/impressions and/or recommended studies Risks and benefits of treatment options
Instruction for management/treatment and/or follow-up Importance of compliance with chosen treatment options
Risk Factor Reduction Patient/Family/Caregiver Education Prognosis

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Coordination of care provided (with patient present) with (check off as appropriate and describe below):
Coordination with: Nursing Residential Staff Social Work Physician/s Family Caregiver

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Greater than 50% of face to face time spent providing counseling and/or coordination of care: (for E&M part)
Additional Documentation, Therapy provided itp:
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Total time spent : min.
Psychiatrists Signature: Date: