OPD PROGRESS NOTE PSYCHATRIC

ARRIVED TIME : <3>

File No Patient Name Diagnosis
<2> <9> <10> <8>

AGE
<AGE> <12S> - <77> - <5> - <28> - <27> <11>

* Chief complaint : <PNP1>

* The PT is stable and come just to refill medication : <PNP2>
*Short present history : <PNP3>
*Response to current medications : <PNP4>
*current use of illicit drugs : <PNP5>
*current medical problem : <PNP6>
*recent criminal / forensic problem : <PNP7>
Mental Status examination:
*Appearance : <PNP8>
*attitude toward examiner : <PNP9>
*eye to eye contact : <PNP10>
*grooming : <PNP11>
*Abnormal movement : <PNP12>
*Behavior : <PNP13>
*Mood : <PNP14>
* Affect : <PNP15>
*SPEECH : <PNP16>
*thought : <PNP17>
* Content : <PNP18>
* Control : <PNP19>
* suicidal and homicidal ideation : <PNP20>
*Perception : <PNP21>
* Awareness of self & others : <PNP22>
* Consciousness : <PNP23>
* Orientation : To time : <PNP24> To place : <PNP25> To persons : <PNP26>
* Memory: - immediate : <PNP27>
- Recent : <PNP28>
- Remote : <PNP29>
* Attention & concentration : <PNP30>
* General knowledge : <PNP31>
* Intelligence : <PNP32>
* Insight : <PNP33>
* Judgment : <PNP34>
* Diagnosis : <PNP35>
*Assessment : <PNP36>
*Need for hospitalization : <PNP37>
* Availability of bed : <PNP30>