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Advanced Practice Registered Nurse
20-25 minutes

Template for Initial Assessment:

The Initial Evaluation Template by s10.ai is crafted for Nurse Practitioners performing in-depth psychiatric assessments, encompassing critical components such as the patient's primary complaint, psychiatric and medical history, mental status examination, and treatment planning. Perfect for documenting initial evaluations in mental health environments, this template ensures a comprehensive analysis of symptoms, history, and present functioning. It aids in generating a detailed and organized clinical note, thereby improving patient care quality and communication among healthcare professionals. Optimized for integration with AI medical scribe software like s10.ai, it streamlines the documentation process, encouraging clinicians to adopt and explore its benefits.

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Dr. Jonathan Mitchell
Template Structure

Organized sections for comprehensive clinical documentation

Initial Assessment Template:
Identification: [Patient name, age, and gender]
Chief Complaint: [Patient's chief complaint in quotes]
History of Present Illness:
[Brief summary of patient's history of present illness, including onset, duration, and severity of symptoms]
Psychiatric review of systems:
Depressive symptoms: [Description of patient's depressive symptoms]
Anxiety symptoms: [Description of patient's anxiety symptoms]
Sleep: [Description of patient's sleep patterns and any related symptoms]
Appetite: [Description of patient's appetite]
Suicidal and homicidal ideations: [Patient's report of suicidal or homicidal ideations or plans]
Auditory and visual hallucinations: [Patient's report of auditory or visual hallucinations]
Delusions/paranoia: [Description of any delusional or paranoid thinking exhibited by the patient]
Manic symptoms: [Patient's report of manic symptoms]
Past Psychiatric History:
- Prior diagnosis: [Patient's prior psychiatric diagnoses]
- Hospitalizations in psychiatric units: [Patient's history of psychiatric hospitalizations]
- Previous suicide attempts: [Patient's history of suicide attempts]
- History of self harm: [Patient's history of self-harm behaviors]
- Access to firearms: [Patient's access to firearms]
- Psychotropic medications: [Patient's current or past use of psychotropic medications]
- Current psychiatrist and therapist: [Patient's current mental health care providers]
- Cures report: [Availability of patient's CURES report]
Family History of psychiatric/substance use history: [Patient's family history of psychiatric or substance use disorders]
Substance Use History:
- Alcohol: [Patient's alcohol use history and patterns]
- Cannabis: [Patient's cannabis use history]
- Amphetamines: [Patient's amphetamine use history]
- Nicotine: [Patient's nicotine use history]
- Other substances: [Patient's use of other substances]
Medical History: [Patient's reported medical history]
Medical Review of systems: [Results of patient's medical review of systems]
Current Medications: [Patient's current medications]
Allergies: [Patient's known allergies]
Social History:
- Marital Status: [Patient's marital status]
- Children: [Number and ages of patient's children, if applicable]
- Living situation: [Patient's current living situation]
- Employment: [Patient's employment status and details]
- Education: [Patient's educational background]
- Support System: [Patient's support system, including family and friends]
Objective:
Mental Status Evaluation:
Appearance: [Description of patient's appearance]
Cognition: [Assessment of patient's cognitive functioning]
Speech: [Description of patient's speech patterns]
Mood: [Patient's reported mood]
Affect: [Description of patient's affect]
TP: [Assessment of patient's thought process]
TC: [Assessment of patient's thought content, including suicidal/homicidal ideations and delusions]
Perc: [Assessment of patient's perceptual disturbances, including auditory/visual hallucinations]
Insight/Judgment: [Assessment of patient's insight and judgment]
Assessment:
[Summary of patient's presentation, target symptoms, and diagnostic impressions]
Plan:
1. Risk Assessment: [Assessment of patient's risk for danger to self or others, including protective factors and safety planning]
2. Status: [Patient's treatment status (e.g., voluntary, involuntary)]
3. Diagnostics: [Diagnostic tests or referrals, if applicable]
4. Treatment:
5. Bio: [Biological interventions, including medication management and discussion of risks/benefits/side effects]
6. Psychosocial: [Psychosocial interventions, including therapy modalities, safety planning, and referrals]
7. Patient's Participation in treatment plan: [Patient's understanding and willingness to engage in treatment]
Therapeutic Interventions: [Type of therapy/approach used and duration of session]
Symptoms or Challenges Discussed: [Specific symptoms or challenges addressed in the therapy session]
Impact on the Patient's Functioning: [Description of how the patient's symptoms impact their functioning]
Specific Topics Covered: [Topics discussed during the therapy session]
Client's Response: [Patient's response to the therapeutic interventions]
Prognosis: [Assessment of patient's prognosis and risk for decompensation]
Diagnosis:
[Patient's psychiatric diagnoses with ICD-10 codes]
Billing Codes:
[Applicable billing codes for the services provided]
Provider's name:
[Provider's name]
Sample Clinical Note

Example of completed documentation using this template

Initial Evaluation Template:
Identification: John Doe, 45, Male
Chief Complaint: "I have been feeling extremely anxious and unable to sleep for the past few weeks."
History of Present Illness:  
John Doe describes a gradual onset of anxiety symptoms over the past month, with increasing severity. He mentions difficulty sleeping, feeling restless, and experiencing frequent worry about work and personal life.
Psychiatric review of systems:  
Depressive symptoms: Reports feeling down and lacking energy.  
Anxiety symptoms: Experiences excessive worry and restlessness.  
Sleep: Reports difficulty falling and staying asleep.  
Appetite: Decreased appetite noted.  
Suicidal and homicidal ideations: Denies any suicidal or homicidal thoughts.  
Auditory and visual hallucinations: Denies any hallucinations.  
Delusions/paranoia: No delusional or paranoid thoughts reported.  
Manic symptoms: Denies any manic symptoms.
Past Psychiatric History:  
- Prior diagnosis: Generalized Anxiety Disorder  
- Hospitalizations in psychiatric units: None  
- Previous suicide attempts: None  
- History of self harm: None  
- Access to firearms: No access  
- Psychotropic medications: Previously prescribed Sertraline  
- Current psychiatrist and therapist: Dr. Emily Smith, Therapist: Jane Doe  
- Cures report: Available
Family History of psychiatric/substance use history: Mother with history of depression
Substance Use History:  
- Alcohol: Occasional use, 1-2 drinks per week  
- Cannabis: None  
- Amphetamines: None  
- Nicotine: Smokes 5 cigarettes per day  
- Other substances: None
Medical History: Hypertension, managed with medication
Medical Review of systems: No significant findings
Current Medications: Lisinopril 10mg daily
Allergies: Penicillin
Social History:  
- Marital Status: Married  
- Children: Two children, ages 10 and 12  
- Living situation: Lives with spouse and children  
- Employment: Works as an accountant  
- Education: Bachelor's degree in Accounting  
- Support System: Strong family support
Objective:  
Mental Status Evaluation:  
Appearance: Well-groomed, casually dressed  
Cognition: Alert and oriented  
Speech: Normal rate and volume  
Mood: Anxious  
Affect: Congruent with mood  
TP: Logical and coherent  
TC: No suicidal or homicidal ideations, no delusions  
Perc: No perceptual disturbances  
Insight/Judgment: Good insight and judgment
Assessment:  
John Doe presents with symptoms consistent with Generalized Anxiety Disorder, exacerbated by recent stressors.
Plan:  
1. Risk Assessment: Low risk for self-harm, protective factors include family support  
2. Status: Voluntary  
3. Diagnostics: None indicated at this time  
4. Treatment:  
5. Bio: Restart Sertraline 50mg daily, discuss potential side effects  
6. Psychosocial: Cognitive Behavioral Therapy, safety planning, referral to support group  
7. Patient's Participation in treatment plan: Patient is willing to engage in therapy and medication management
Therapeutic Interventions: Cognitive Behavioral Therapy, 60-minute session  
Symptoms or Challenges Discussed: Anxiety management, sleep hygiene  
Impact on the Patient's Functioning: Anxiety impacting work performance and family interactions  
Specific Topics Covered: Coping strategies, relaxation techniques  
Client's Response: Patient engaged and receptive to interventions  
Prognosis: Good, with adherence to treatment plan
Diagnosis:  
Generalized Anxiety Disorder (F41.1)
Billing Codes:  
99205, 90834
Provider's name:  
Dr. Thomas Kelly
Clinical Benefits

Key advantages of using this template in clinical practice

  • The Initial Evaluation Template is an essential tool for clinicians seeking a comprehensive and structured approach to patient assessment. This template facilitates the thorough documentation of a patient's chief complaint, history of present illness, and psychiatric review of systems, ensuring no critical detail is overlooked. It includes sections for past psychiatric history, family history, substance use, and medical history, providing a holistic view of the patient's background. The template also covers social history and objective mental status evaluation, aiding in accurate diagnosis and treatment planning. With dedicated areas for assessment, risk evaluation, and therapeutic interventions, this template supports clinicians in developing personalized care plans. By adopting this template, healthcare professionals can enhance their clinical documentation, improve patient outcomes, and streamline their workflow, making it an invaluable resource for any mental health practice.
Frequently Asked Questions

Common questions about this template and its usage

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