Mercy_BH_documentation___tx_plan_templates_EPIC
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Meharry Medical College *
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101
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Health Science
Date
Jan 9, 2024
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docx
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This is a series of several “smart phrases” for Epic. It includes an initial assessment, progress note, and treatment plan. These were developed for Ohio by Linda Myerholtz, Ph.D. and may not meet documentation standards in other states.
Initial Asssessment:
Behavioral Health Assessment
Mercy Family Medicine
Time Start:
*** pm
Time End: *** pm
Date of Service:
@ed@
Basis of Evaluation: Clinical Interview Review of Medical Record
PHQ Interview family member
Presenting Concerns:
@name@ is a @age@ {Race/ethnicity:17218} @sex@ who was referred by @his@ primary care physician, @pcp@, due to concerns about ***.
@fname@ reported the following symptoms of depression: {Symptoms; depression:1002}. @CAPHE@ also reported {PSYC MOOD CHANGES:20036}. In addition, @fname@ reported symptoms of {FA AMB ANXIETY:21418}. There is no evidence of mania or a thought disorder.
@CAPHE@ reported that @his@ symptoms began ***.
Previous behavioral health treatment history: {Psych history:31879}
@CAPHE@ is currently being prescribed {Meds; antidepressants:60303} by @his@ ***. @fname@ @sochxp@
Mental Status:
Appearance:
{Exam; general psych:31883}
Affect:
{MS AMB PSYCH MSE AFFECT:21395}
Mood:
{MS AMB PSYCH MSE MOOD:21394}
Thought Process:
{MS AMB PSYCH MSE THOUGHT PROCESS:21396}
Delusions:
{DELUSIONS:304650270}
Perceptions:
{MS AMB PSYCH MSE PERCEPTIONS:21399}
Behavior: {BEHAVIORAL APPROACH:304650147}
Psychomotor:
{MS AMB PSYCH MSE PSYCHOMOTOR:21392}
Speech: {MS AMB PSYCH MSE SPEECH:21393}
Eye Contact:
{BEHAV EYE CONTACT:20909}
Orientation: {Exam; orientation:10007}
Judgment & Insight:
{Exam; psychiatric judgement/insight:30303}
Risk Assessment:
Current Suicide Risk: {SUICIDE:304650257}
Current Homicide Risk: {HOMOCIDE:304650260}
@fname@ reported ***.
Social History/Functioning:
@fname@ is currently living {Living arrangements:60532} and reported {SOCIAL SUPPORT:304650078}.@CAPHE@ denied any current cultural or spiritual concerns. @sochx@
@pmh@
Diagnosis:
Axis 1: {MS AMB PSYCH AXIS I:21407}
Axis II: {PSYL PSYC DX AXIS-2:20060}
Axis III:
See past medical history listed above
Axis IV: {PSYC AXIS IV:20057}
Axis V: {RUSH DH PSYCH EVAL GAF:1332000609}
Strengths: ***
Limitations: ***
Initial Treatment Plan/Recommendations:
Individual behavioral health therapy is recommended for @fname@. Treatment will be coordinated with @fname@'s primary care physician. Frequency of Service: We will begin to meet every {Time; 1 week to 1 month:10250}. Frequency of sessions will decrease as patient reaches @his@ treatment goals.
Projected Discharge Date: {Time; 3 months to 1 year:10399}
(insert treatment plan here) ***
Patient Response to Plan/Recommendations:
Discussed initial diagnosis and treatment recommendations with @fname@. Explained the risks and benefits of psychotherapy. Discussed options/alternative for treatment. Developed treatment plan above with @fname@. @fname@ verbalized understanding and agreement with treatment plan. Discussed confidentiality and limits of confidentiality as it applies to mental health treatment. Reviewed the behavioral health informed consent form with @fname@ and provided an opportunity for @him@ to ask questions. @fname@ verbalized understanding of informed consent form and agreed to enter treatment.
Provided @fname@ with Behavioral Heath clinic brochure that outlines how @he@ can reach me and the office and provided @him@ with instructions on how to contact Rescue Crisis in the event that this therapist cannot be reached or if @he@ has an emergency/crisis.
Progress Note
Individual Behavioral Health Progress Note
Mercy Family Medicine
Start Time:
*** pm
End Time:
*** pm
Date of Service:
@ed@
Mental Status/Behavioral Observations
Affect:
{MS AMB PSYCH MSE AFFECT:21395}
Mood:
{MS AMB PSYCH MSE MOOD:21394}
Thought Process:
{MS AMB PSYCH MSE THOUGHT PROCESS:21396}
Behavior: {BEHAVIORAL APPROACH:304650147}
Self Harm:
{SUICIDE:304650257}
Interventions Provided:
***
Patient Response/Progress:
***
Additional Information/Plan:
Will continue with treatment plan. @FOLLOWUP@
Treatment Plan Template
Behavioral Health Treatment Plan
Start Date of Plan:
@ed@
Services: Individual behavioral health counseling/psychotherapy
Strengths: ***
Limitations: ***
Frequency of Service:
We will meet every {Time; 1 week to 1 month:10250}. Frequency of sessions will decrease as @fname@ reaches @HIS@ treatment goals.
Projected Discharge Date
: {Time; 3 months to 1 year:10399}
Date of Next Review: 6 months
This plan was developed collaboratively with @fname@. Discussed therapeutic interventions designed to assist @him@ in reaching @his@ goals and objectives. @fname@ verbalized understanding and agreement with the goals, objectives and interventions. (goals/objectives smart phrase here) ***
Treatment Plan Review
Reviewed treatment plan with @fname@. Discussed treatment progress and plans to continue therapy. @CAPHE@ agreed to continue with treatment plan as noted below.
Current Treatment Plan:
***
Treatment Progress Summary:
***
Current GAF: {RUSH DH PSYCH EVAL GAF:1332000609}
Extending Treatment Discharge Date? {YES***/NO:60}
Modifying Treatment goals/objectives? {YES***/NO:60}
Modifying Service Frequency?
{YES***/NO:60}
Modifying Diagnosis?
{YES***/NO:60}
Sample Treatment Plan “templates”- I use these to begin the development of a treatment plan with the patient and they are then modified to meet the needs of each individual patient. Each “template” is a smart phrase.
Anxiety:
Goal: To gain skills to minimize and manage worries, fears, panic and other symptoms of anxiety
Objective
Intervention
Date
added to
Plan
Target Date
@fname@ will develop a hierarchy of anxiety producing situations and thoughts and gradually expose @him@self to these situations while using anxiety management skills
Systematic Desensitization (education @fname@ on purpose; Develop Hierarchy: Begin gradual exposure to items on hierarchy while utilizing anxiety management strategies)
@ed@
***
@fname@ will learn to identify and challenge needs or tendencies which predispose a person to anxiety (need to control, perfectionism, need for approval, self criticism, catastrophizing, etc)
Cognitive Behavioral Therapy (CBT) to assist @fname@ in understanding emotional, cognitive, and behavioral components of anxiety; develop skills to manage anxiety symptoms
@ed@
***
@fname@ will learn to recognize the physical signs of anxiety and recognize that these are normal body reactions
CBT @ed@
***
@fname@ will learn to identify anxiety
producing thoughts and self statements and develop and use appropriate counter statements
Analyze @fname@'s fear/worry by examining the probability of the negative expectation occurring, the real consequences of it occurring, @fname@'s ability to control the outcomes, the worst possible outcome, and @his@ ability to accept it
@ed@
***
@fname@ verbalize an understanding
CBT
@ed@
***
of the connection between anxiety producing thoughts and the physical symptoms of anxiety
@fname@ will learn various relaxation
skills (i.e. progressive muscle relaxation, guided imagery, relaxation breathing, meditation, etc.) and begin to use these skills
Teach @fname@ relaxation strategies (i.e. progressive muscle relaxation, guided imagery,
deep breathing, etc.)
@ed@
***
@fname@ will verbalize understanding of how self care activities (good nutrition, good sleep hygiene, reducing caffeine intake, moderate exercise, self nurturing activities) impact emotional well-being and will develop and implement a plan
to increase self nurturing activities.
Assist @fname@ in developing an understanding of healthy life- style skills (i.e. nutrition, exercise, sleep, decreasing caffeine, etc.). Develop plan to increase healthy activities. Provide positive reinforcement for taking action steps toward a healthier life-style.
@ed@
***
Depression
Goal: To develop skills to manage and/or eliminate depressive symptoms and improve how I feel about myself
Objective
Intervention
Date
added to
Plan
Target Date
@fname@ will verbalize understanding
of how self care activities (good nutrition, good sleep hygiene, moderate exercise, self nurturing activities) impact emotional well-being and will develop and implement a plan to increase self nurturing activities.
Assist @fname@ in developing an understanding of healthy life- style skills (i.e. nutrition, exercise, sleep, etc.). Develop plan to increase healthy activities. Provide positive reinforcement for taking action steps toward a healthier life-style.
@ed@
***
@fname@ will learn to identify negative dysfunctional thoughts, challenge them, and replace them with Cognitive Behavioral Therapy (CBT) to assist @fname@ in increasing awareness of link between emotions, thoughts and behaviors; @ed@
***
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