This is the intake template that I use and that transcription has at my place. I use the same to jot down notes when interviewing a patient. It's kinda jacked after loading it here but you can see it's pretty standard for most part.
NEW PATIENT INTAKE
E&M NOTE: Time Start: Time End:
IDENTIFYING DATA:
CHIEF COMPLAINT:
REFERRED BY:
HISTORY OF PRESENT ILLNESS:
PSYCHIATRIC HISTORY:
MEDICAL HISTORY:
SUBSTANCE HISTORY:
ALLERGIES:
CURRENT MEDS:
SUPPLEMENTS:
DIET:
CAM THERAPIES:
FAMILY MEDICAL HISTORY:
FAMILY PSYCHIATRIC HISTORY:
SOCIAL HISTORY:
REVIEW OF BHDP:
REVIEW OF SYSTEMS: []Const []Eyes []ENT/Mouth []CV []Resp []GI []GU []Skin/Breasts []Neuro
[]Endocrine []Hem/Lymph []Allergy/Immune []Musculoskeletal []OB/GYN
*Note: All reviewed. Findings:
VITAL SIGNS:
BP:
P:
WT:
BMI:
MUSCULOSKELETAL: ()Strength Normal/=Bilaterally ()Normal Gait/Station ()Other:
MENTAL STATUS EXAMINATION:
Appearance: (x)WDWN ()Well Groomed ()Injuries/Pain ()Assist Devices ()Other:
Behavior: (x)Cooperative ()Guarded ()Hostile ()Other:
Speech/Language: (x)Normal ()Delayed ()Excessive ()Paucity ()Pressured ()Other:
Mood: Affect: (x)Normal Range ()Tearful ()Labile ()Constricted ()Flat ()Other:
Thought Process: (x)LLGD ()Disorganized ()Tangential ()Circumstantial ()Other:
Thought Content: (x)Unremarkable ()SI ()HI ()AH ()VH ()Delusions ()Mania ()O/C ()Other:
Orientation: (x)Time ()Place ()Person ()Situation ()Other:
Memory: (x)Intact Recent (x)Intact Remote ()Other:
Attention/Concentration: (x)Intact ()Distractible/Inattentive ()Other:
Judgment/Insight: (x)Good ()Fair ()Poor ()Other:
Fund of Knowledge: (x)Education/Age Appropriate ()Other:
Impulse Control
x)Appropriate ()Poor due to:
RISK ASSESSMENT:
Risk for: ()None ()Suicide ()Homicide ()AWOL *Note:
Protective Factors: ()Family ()Career ()Pet ()Religion ()Resiliency *Other:
Safety Plan: ()Walk-in ()Command ()Chaplain ()ED *Other:
Patient demonstrates enough practical judgment and impulse control to believe that they can self-monitor and access crisis care if needed.
ASSESSMENT/IMPRESSION:
Axis I:
Axis II:
Axis III:
PLAN:
1. Meds:
2. Labs:
3. Next Visit:
4. Consults/Referrals:
5. Therapist:
6. Profile:
7. Polypharmacy:
8. Other:
TREATMENT GOALS/TIME FRAME:
(x)To achieve highest possible remission of symptoms considering all factors involved. (x)To provide optimal level of individualized care to patient. (x)To continually reassess and make needed revisions in care of patient. (x)To make appropriate referrals when indicated. (x)To accomplish highest possible remission in 6-12 months.
EDUCATION:
(x)Key risks & benefits of medication regimen have been discussed & patient has verbalized understanding and consents to prescribed medications. (x)Patient has been informed how to obtain refills, to call in if no refills remain, and to use meds only as prescribed. (x)Meds will be used for FDA approved conditions, or if used off-label, rationale for their use will be documented. (x)Med education form for the prescribed drug(s) provided either by pharmacy or prescriber. (x)The patient has been educated on realistic expectations from treatment & necessity for internal drive to recover as well as personal responsibility for compliance. (x)The patient verbalizes understanding & agreement with the overall treatment goals and plan.