Self-Harm

Patient presents with self-harm behaviors, specifically (describe method of self-harm e.g., cutting, burning, scratching).  Assessment reveals (describe location, depth, and extent of injuries; note presence of scarring or previous self-harm).  Patient reports (patient's stated reason for self-harm; include direct quotes where relevant, avoiding judgmental language).  Mental status examination indicates (describe patient's affect, mood, thought processes, and suicidal ideation; note any signs of depression, anxiety, or other mental health conditions).  Differential diagnoses considered include nonsuicidal self-injury, borderline personality disorder, major depressive disorder, and post-traumatic stress disorder.  Diagnosis of Nonsuicidal Self-Injury (NSSI) is made based on patient history, presentation, and meeting criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).  Treatment plan includes (specify interventions e.g., safety planning, cognitive behavioral therapy CBT, dialectical behavior therapy DBT, referral to psychiatrist, medication management).  Patient education provided on coping mechanisms, stress management techniques, and available resources for self-harm support.  Risk assessment conducted, and current level of suicide risk determined to be (state level of risk: low, moderate, high).  Follow-up appointment scheduled for (date and time) to monitor progress and adjust treatment as needed.  ICD-10 code F68.8 (Other specified impulse control disorders) or other appropriate code based on specific presentation may be utilized for billing and coding purposes.  CPT codes for evaluation and management, psychotherapy, and other provided services will be documented accordingly.  Patient advised to contact emergency services or crisis hotline if self-harm urges escalate.