Detailed Psychiatric SOAP with E/M Coding Template

Visit Title: Anxiety and Academic Performance
Chief Complaint:
- "I'm feeling overwhelmed and anxious about school."
HPI/Interim History:
The patient, a 15-year-old female, reports increased anxiety over the past three months, particularly related to academic performance. She denies any substance use. The anxiety is impacting her ability to concentrate and complete assignments, leading to a decline in grades. She has not required a leave of absence but is concerned about her academic future.
Psychotherapy and Psychotherapeutic Interventions:
- 180 minutes spent on therapy focusing on anxiety management
- Discussed coping strategies for school-related stress and time management
- Utilized cognitive-behavioral therapy (CBT) and mindfulness techniques, which the patient found helpful
- Target symptoms: Anxiety, stress
- Progress towards treatment goals: Moderate improvement in managing anxiety
- Techniques used: CBT, mindfulness
Current Medications Discussed:
- Sertraline 50 mg daily: Effective with mild side effects of drowsiness, good adherence
- No changes to medications
Pertinent Past Medications and Psychiatric Treatments:
- Previously trialed fluoxetine with limited efficacy
- No history of TMS, ECT, or other advanced treatments
- No past psychiatric hospitalizations
Objective:
Mental Status Exam
- General Appearance and Behavior: Well-groomed, cooperative
- Motor abnormalities: No abnormal motor movements
- Speech: Normal rate, rhythm, and prosody
- Eye contact: Consistent
- Affect: Congruent, anxious
- Mood: "Anxious"
- Thought content: Preoccupied with academic performance
- Thought process: Linear and goal-directed
- Cognition: Grossly intact attention and memory
- Orientation: Alert and oriented
- SI, HI, Violent ideation: Absent
- Insight and judgment: Good insight, fair judgment
DATA (billed)
- GAD-7 completed, score: 15 (moderate anxiety)
- No labs or other studies referenced
Clinical Global Impressions:
- CGI-S (Severity): 4 (Moderate) - Due to significant anxiety impacting daily functioning
- CGI-I (Improvement): 3 (Minimal improvement) - Some progress with therapy and medication
Assessment and Plan:
- Generalized Anxiety Disorder: Moderate anxiety impacting school performance, continue CBT and sertraline
- Academic Stress: Addressed through therapy, continue monitoring
- Overall: Patient shows moderate improvement, continue current treatment plan
Risk Assessment:
- No current concerns for self-harm or violence
- Protective factors: Supportive family, engaged in therapy
- Risk factors: Academic stress, anxiety
- No escalation of care needed
Medication and Interventions Plan:
- Continue sertraline 50 mg daily
- Discussed risks and benefits of medication, patient and family in agreement
- No new research studies mentioned
Tests and Studies: No tests or studies ordered
Collaboration Plan:
- Coordinating with school counselor for academic support
- Family involved in therapy sessions
- No additional collateral information needed
Medical Decision Making:
- Considered patient's academic stress and anxiety levels
- E/M Code: 99214 (Established patient, moderate complexity) - Due to moderate complexity of anxiety management
Interactive Complexity Present: Not applicable
Followup:
- Next appointment scheduled for 15 November 2024
- No discharge plan needed