cpe

Comprehensive Psychiatric Evaluation Template

With Psychotherapy Note

Encounter date: ________________________

Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

Reason for Seeking Health Care: ______________________________________________

HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SI/HI: _______________________________________________________________________________

Sleep:  _________________________________________         Appetite:  ________________________

Allergies (Drug/Food/Latex/Environmental/Herbal): ___________________________________ Current perception of Health: Excellent Good Fair Poor

Psychiatric History:

Inpatient hospitalizations:

Date	Hospital	Diagnoses	Length of Stay

Outpatient psychiatric treatment:

Date	Hospital	Diagnoses	Length of Stay

Detox/Inpatient substance treatment:

Date	Hospital	Diagnoses	Length of Stay

History of suicide attempts and/or self injurious behaviors: ____________________________________

Past Medical History

· Major/Chronic Illnesses____________________________________________________

· Trauma/Injury ___________________________________________________________

· Hospitalizations __________________________________________________________

Past Surgical History___________________________________________________________

Current psychotropic medications:  

_________________________________________ ________________________________

_________________________________________ ________________________________

_________________________________________ ________________________________

Current prescription medications:  

_________________________________________ ________________________________

_________________________________________ ________________________________

_________________________________________ ________________________________

OTC/Nutritionals/Herbal/Complementary therapy:

_________________________________________ ________________________________

_________________________________________ ________________________________

Substance use : (alcohol, marijuana, cocaine, caffeine, cigarettes)

Substance	Amount	Frequency	Length of Use

Family Psychiatric History: _____________________________________________________

Social History

Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________

Education:____________________________

Employment Status: ______ Current/Previous occupation type: _________________

Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________

Sexual Orientation: _______ Sexual Activity: ____ Contraception Use: ____________

Family Composition: Family/Mother/Father/Alone : _____________________________

Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________

________________________________________________________________________

Health Maintenance

Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia

Exposures:

Immunization HX:

Review of Systems (at least 3 areas per system):

General:

HEENT:

Neck:

Lungs:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Activity & Exercise:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

Physical Exam

BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI ( percentile) _____

General:

HEENT:

Neck:

Pulmonary:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Derm:

Psychosocial:

Misc.

Mental Status Exam

Appearance:

Behavior:

Speech:

Mood:

Affect:

Thought Content:

Thought Process:

Cognition/Intelligence:

Clinical Insight:

Clinical Judgment:

Psychotherapy Note

Therapeutic Technique Used:

Session Focus and Theme:

Intervention Strategies Implemented:

Evidence of Patient Response:

Plan:

Differential Diagnoses

1.

2.

Principal Diagnoses

1.

2.

Plan:

Diagnosis #1

Diagnostic Testing/Screening:

Pharmacological Treatment:

Non-Pharmacological Treatment:

Patient/Family Education:

Referrals:

Follow-up:

Anticipatory Guidance:

Diagnosis #2

Diagnostic Testing/Screening Tool:

Pharmacological Treatment:

Non-Pharmacological Treatment:

Patient/Family Education:

Referrals:

Follow-up:

Anticipatory Guidance:

Signature (with appropriate credentials): __________________________________________

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________

DEA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age ___________

Date: _______________

RX ______________________________________

SIG:

Dispense: ___________ Refill: _________________

No Substitution

Signature: ____________________________________________________________

Rev. 2272022 LM