Follow-Up Medication Management Note

ENCOUNTER TYPE: [Telepsychiatry / In-Person] — Follow-Up Psychiatric Medication Management DATE: [MM/DD/YYYY] | TIME: [HH:MM] – [HH:MM] | DURATION: [## min] // Telepsychiatry only — include below: PLATFORM: [Doxy.me / Zoom for Healthcare / Epic MyChart / Other] PATIENT LOCATION: [City, State — patient confirmed] PROVIDER LOCATION: [Clinic Name, City, State] TELEHEALTH CONSENT: Previously obtained and on file / Re-confirmed today IDENTITY VERIFIED: [DOB / Photo ID] CONNECTION QUALITY: [Audio: Clear | Video: Clear] / [Audio-only — reason: ___] PATIENT: [Full Name] | DOB: [MM/DD/YYYY] | MRN: [___] LAST VISIT: [Date] — [Provider Name, credentials] VISIT SINCE: [## days / weeks / months since last contact] ACCOMPANYING: [Alone / With: Name, relationship]

INTERVAL HISTORY: Patient returns for follow-up medication management, [## days/weeks] since last visit. Overall interval course: [Improved / Stable / Worse / Mixed] SYMPTOM CHANGES: [Depression/anxiety/mood/psychosis/etc.] — [improved/worsened/unchanged since last visit] Patient reports: "[Brief quote from patient re: how they've been doing]" SIGNIFICANT INTERVAL EVENTS: [ ] No significant events between visits [ ] Psychiatric hospitalization: [Date, facility, duration, reason, discharge Rx] [ ] ER visit (psychiatric): [Date, reason, outcome] [ ] Crisis line contact: [Date, reason, outcome] [ ] New medical diagnosis or hospitalization: [___] [ ] Major life event: [Loss / Relationship change / Job change / Legal issue / Other: ___] [ ] New medications from another provider: [___] [ ] Substance use relapse: [Substance, date, context, current status] THERAPY ATTENDANCE: [Attending therapy with ___: [Consistently / Inconsistently / Discharged / Not in therapy] Therapy engagement: [Productive / Struggling / Session count since last visit: ___] BETWEEN-VISIT CONTACTS: [No between-visit contacts / Phone triage call [date] re: ___] [Message via portal [date] re: ___]

CURRENT MEDICATIONS: Medication | Dose | Freq | Adherence | Patient Report --------------------|------------|--------|-----------------|------------------ [Drug 1] | [dose] | [freq] | [100%/partial] | [Helpful/Tolerated] [Drug 2] | [dose] | [freq] | [partial/%] | [Side effects: ___] [Drug 3] | [dose] | [freq] | [Non-adherent] | [Reason: cost/SE/forgot] ADHERENCE SUMMARY: Overall adherence: [Good (>80%) / Partial (50-80%) / Poor (<50%) / Non-adherent] Barriers identified (if applicable): [ ] Cost / copay burden — addressed: [GoodRx / generic / manufacturer coupon / PAP] [ ] Side effects — addressed: [Dose adjustment / Timing change / Medication switch] [ ] Forgetting — addressed: [Pillbox / Phone reminder / Once-daily formulation] [ ] Stigma — addressed: [Psychoeducation provided] [ ] Lack of perceived benefit — addressed: [___] [ ] No barriers identified PRESCRIPTION REFILLS TODAY: [List medications refilled, quantities, days supply] [No refills needed at this time] PHARMACY: [Pharmacy name, address — or patient-confirmed pharmacy on file]

PDMP REVIEW: Date/time accessed: [MM/DD/YYYY HH:MM] Database: [State PDMP name] [ ] PDMP accessed — No controlled substance prescriptions outside of expected Current controlled substance prescribers: [This practice only / List if multiple] [ ] PDMP accessed — Findings consistent with clinical picture: [Drug, Dose, Prescriber, Date, Pharmacy — all expected] [ ] PDMP accessed — Unexpected findings: Finding: [___] Clinical response: [Patient education / Referral / Dose adjustment / Contact other prescriber / No change warranted because: ___] [ ] PDMP not accessed — Reason: [Patient not receiving controlled substances / State system unavailable — alternative verification: ___] // Document even if not prescribing controlled substances — best practice for all patients // Required before prescribing any new controlled substance in most states

URINE DRUG SCREEN: TODAY: [ ] Not ordered today — reason: [___] [ ] Ordered — point of care / lab send-out — results pending [ ] Results available (date collected: ___): RESULTS: Amphetamines: [Neg / Pos — expected: Y/N] Benzodiazepines: [Neg / Pos — expected: Y/N] Cannabis (THC):[Neg / Pos — expected: Y/N] Cocaine: [Neg / Pos — expected: Y/N] Opiates: [Neg / Pos — expected: Y/N] Oxycodone: [Neg / Pos — expected: Y/N] Fentanyl: [Neg / Pos — expected: Y/N] Buprenorphine: [Neg / Pos — expected: Y/N] Methamphetamine:[Neg / Pos — expected: Y/N] PCP: [Neg / Pos — expected: Y/N] Alcohol (EtG): [Neg / Pos — expected: Y/N] Other: [___] EXPECTED SUBSTANCES: [List patient's prescribed medications that may appear positive] INTERPRETATION: [ ] All results consistent with prescription and treatment plan — no action needed [ ] Prescribed substance absent — discussed: [Non-adherence / Diversion / Delay in testing] Response: [___] [ ] Unexpected substance present — discussed: [Not punitive — therapeutic conversation] Finding: [___] Patient explanation: [___] Clinical response: [___] // Never interpret a positive result punitively without clinical conversation first // Confirm-positive tests with quantitative lab if clinical decision depends on it // False positives: quinolones → opiates; ibuprofen → cannabis; sertraline → BZD

MENTAL STATUS EXAMINATION: Appearance: [Well-groomed / Adequate / Disheveled] | Age: [appropriate / appears older/younger] Behavior: [Cooperative / Guarded / Agitated / Pleasant] Psychomotor: [No abnormalities / Agitation / Retardation / Tremor — specify: ___] Eye contact: [Good / Poor / Avoidant] Speech: [Rate: Normal/Rapid/Slow | Volume: Normal/Loud/Soft | Rhythm: Normal/Pressured] Mood (S): "[Patient's own words]" Affect (O): [Euthymic / Depressed / Anxious / Irritable / Elevated / Labile / Flat] Range: [Full / Restricted / Blunted] | Congruence: [Congruent / Incongruent] Thought Process: [Linear, logical, goal-directed / Circumstantial / Tangential / Other: ___] Thought Content: SI: [None / Passive / Active — see Risk Assessment] HI: [None / Present: ___] Delusions: [None / Present: ___] Obsessions: [None / Present: ___] Perceptual: [No hallucinations / AH: ___ / VH: ___ / Other: ___] Cognition: [Alert and oriented ×4 / Attention intact / Memory intact] [Any cognitive concerns: ___] Insight: [Full / Partial / Poor / Absent] Judgment: [Good / Fair / Poor] // Compared to last visit: [Improved / Stable / Worse] in: [specific domains]

RISK ASSESSMENT: SUICIDALITY: Current SI: [None / Passive: "I wish I were dead" / Active without plan / Active with plan: ___] Since last visit: [No new SI / New SI — addressed: ___] Current intent: [None / Present — action taken: ___] If SI present: Plan: [None / Yes: ___] Access to means: [No firearms / Firearms — secured: Y/N / Other: ___] Intent: [None / Uncertain / Clear] Deterrents: [Family / Children / Fear / Religious beliefs / Other: ___] SELF-HARM: Current NSSI: [None / Yes — type: ___, frequency: ___, last occurrence: ___] HOMICIDALITY: Current HI: [None / Present — target: ___, plan: ___, action: ___] Duty to warn assessed: [N/A / Yes — action: ___] RISK CHANGE FROM LAST VISIT: [Risk stable / Risk decreased / Risk increased — specify: ___] RISK LEVEL: Acute: [Low / Moderate / High / Imminent] Chronic: [Low / Moderate / High] DISPOSITION RATIONALE: [Patient is appropriate for outpatient management because: ___] [OR: Patient requires higher level of care because: ___] SAFETY PLAN: [Previously established — reviewed today / Updated today / Crisis resources re-provided] 988 Suicide & Crisis Lifeline reviewed: [Y/N] Patient's crisis contacts: [___]

ASSESSMENT: [Patient name] returns for follow-up medication management. [He/She/They] reports [subjective improvement/worsening/stability] in [target symptoms]. PHQ-9 today [___] vs. prior [___] = [improved/worsened/stable by ## points]. GAD-7 today [___] vs. prior [___] = [improved/worsened/stable]. Medication response: [Responding well / Partial response / Non-response — see plan] Adherence: [Good / Partial / Poor — see above] Side effects: [None reported / Manageable / Limiting — see above] ACTIVE DIAGNOSES: 1. [F32.1] Major Depressive Disorder, [severity] — [improving/stable/exacerbating] 2. [F41.1] Generalized Anxiety Disorder — [status] 3. [F10.20] Alcohol Use Disorder, moderate — [in remission / active] // Include all active diagnoses with ICD-10 codes at each visit COMORBID MEDICAL CONDITIONS (relevant): [List with impact on psychiatric management] CLINICAL REASONING: [Narrative summary of why you are making the treatment decisions in the plan below. What is driving the change? What are you monitoring for? What's the timeline?]

ACTION: CONTINUE [Drug Name] [Dose] [Frequency] Indication: [Diagnosis] — [FDA-Approved / Off-Label] Response to date: [Partial response / Good response / Stable on current dose] Rationale: [Why continue at current dose: ___] Risk/Benefit: Continuing current regimen. Ongoing risks include [relevant SE for this patient — e.g., weight gain, sexual dysfunction, metabolic effects]. Benefits of [symptom control / functional improvement] outweigh risks. Patient [agrees to continue / acknowledges risks]. Monitoring: [Ongoing: weight, BP, labs — next lab due: ___] Refill: [Qty: ___ | Days supply: ___ | Refills: ___]

ACTION: START [Drug Name] [Dose] [Frequency] Indication: [Diagnosis] — [FDA-Approved / Off-Label] Rationale: [Why this drug? Why now? What drove this decision? Prior trial failures: ___. Patient factors: ___. Formulary/cost considerations: ___.] Risk/Benefit: Discussed risks including [specific side effects relevant to THIS patient — e.g., "nausea and sexual dysfunction common with SSRIs; rare risk of serotonin syndrome; black box warning re: suicidality in patients <25 years old — patient is ___ years old"]. Benefits of [expected therapeutic effect] outweigh risks. Alternatives discussed: [___]. Patient agreed to start. Instructions: [Take [with/without food], [time of day], [titration: ___]] Monitoring: [Follow-up in ## weeks; call if [specific symptoms]] Starting dose: [___ mg] — titrate to [___ mg] at [timeframe] Rx: [Qty: ___ | Days supply: ___ | Refills: ___]

ACTION: CHANGE [Drug Name] dose from [old dose] to [new dose] [Frequency] Indication: [Diagnosis] — [FDA-Approved / Off-Label] Rationale: [Why changing dose? Partial response requiring optimization / Side effect at current dose / Patient request / Therapeutic level below range: ___] Risk/Benefit: Increasing dose carries risk of [dose-dependent side effects: ___]. Decreasing dose carries risk of [symptom return / withdrawal: ___]. Benefits of [rationale for change] outweigh risks. Patient understood and agreed to dose change. Monitoring: [Follow-up timeline: ___ | What to monitor: ___] New Rx: [New Qty: ___ | Days supply: ___ | Refills: ___]

ACTION: DISCONTINUE [Drug Name] [with taper / abruptly — specify] Reason: [Ineffective / Intolerable side effects / Patient request / Drug interaction / No longer indicated / Better alternative started] Taper plan: [Reduce by [dose] every [timeframe] until [final dose/D/C] OR: Abrupt discontinuation — rationale: ___] Discontinuation risk: Discussed potential for [discontinuation syndrome / rebound / symptom return: ___]. Patient instructed to contact office if [___]. Patient acknowledged: Risk of stopping — [agreed to taper plan / understands risks of abrupt DC] Last prescription: [Qty for taper / No new prescription written]

LABS ORDERED: [CMP / CBC / TSH / Lithium level / Valproate level / Lipids / HbA1c / Prolactin / LFTs / Other: ___] [No labs needed today — last drawn [date], results reviewed] REFERRALS: [No new referrals / Referred to: ___ for: ___] [PCP notified of: ___] THERAPY: [Continue with current therapist / Referred for therapy: ___] [Recommended modality change: ___] LIFESTYLE / NON-PHARMACOLOGICAL: [Sleep hygiene reinforced / Exercise discussed / Stress management techniques / Dietary counseling re: medication interactions / Alcohol reduction counseling] PSYCHOEDUCATION TODAY: [Medication mechanism / Side effect management / Relapse warning signs / Diagnosis education / Other: ___] SUBSTANCE USE: [No action needed / SBIRT completed / Referred to: ___ / Naloxone: provided/renewed] CRISIS PLAN: [Reviewed — no changes / Updated / Crisis line reiterated: 988]

FOLLOW-UP: Next appointment: [Date / In ## weeks] Appointment type: [Telepsychiatry / In-Person] Rationale for timing: [ ] Stable — routine follow-up in [4-8 weeks] [ ] New medication started — follow-up in 2-4 weeks to assess response/tolerability [ ] Dose change — follow-up in 2-4 weeks [ ] Elevated risk — follow-up in [1-2 weeks / sooner: ___] [ ] Lab results pending — follow-up in [___] to review Between-visit instructions: Contact us for: [Significant side effects / Worsening SI / Medication questions] After-hours: [Practice after-hours line: ___] Crisis: [988 Suicide & Crisis Lifeline / Local ER: ___] RETURN PRECAUTIONS REVIEWED: Patient instructed to seek emergent care for: - Active suicidal ideation with plan or intent - Active homicidal ideation - Significant medication adverse reaction (rash, chest pain, severe agitation) - [Condition-specific: severe manic symptoms / psychotic break / other: ___] Patient verbalized understanding: [Yes / N/A]

BILLING INFORMATION: CPT CODE: [99214 / 99215] + [90833 add-on if psychotherapy provided] TOTAL TIME: [## minutes total face-to-face and/or administrative time] // If time-based: 99214 = 30-39 min | 99215 = 40-54 min | 99215 = 55+ min MEDICAL DECISION MAKING: Problem complexity: [ ] Chronic illness with exacerbation (moderate-high) [ ] Multiple chronic conditions addressed (high) [ ] New problem addressed in addition to chronic (moderate) [ ] Prescription drug management (moderate) [ ] Drug requiring intensive monitoring — lithium/clozapine/valproate (high) Data: [ ] Reviewed and summarized external records [ ] Reviewed and ordered diagnostic tests [ ] Reviewed standardized instruments (PHQ-9, GAD-7, YMRS) — interpreted results [ ] Independent interpretation of test results Risk: [ ] Controlled substance prescription (moderate-high) [ ] Risk assessment documented with clinical stratification (moderate-high) [ ] Social determinants of health impacting management (moderate-high) [ ] Medication change requiring close monitoring (moderate) PSYCHOTHERAPY ADD-ON (if applicable): [90833 — 16-37 min interactive complexity psychotherapy] [90836 — 38-52 min interactive complexity psychotherapy] Psychotherapy time: [## min] Type: [CBT / Supportive / DBT / Other: ___] Description: [Brief description of psychotherapy content separate from E&M] SUPERVISOR (if applicable): [Collaborating/Supervising Physician: ___, MD/DO] Supervision: [Present / Chart review and countersignature / Available for consultation]