Executive Solution Overview
this soap note will be on a patient you made up who has schizophernia – 2 years ago **files (2)** – ## soapnotemodule3instructuons.docx – ## psychsoapnote.template.docx **## soapnotemodule3instructuons.docx** **Step 1:** You will use the [Graduate Comprehensive Psychiatric Evaluation Template](https…
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this soap note will be on a patient you made up who has schizophernia
– 2 years ago
**files (2)**
– ## soapnotemodule3instructuons.docx
– ## psychsoapnote.template.docx
**## soapnotemodule3instructuons.docx**
**Step 1:** You will use the
[Graduate Comprehensive Psychiatric Evaluation Template](https://stu.instructure.com/courses/43967/files/3410724?wrap=1) [Download Graduate Comprehensive Psychiatric Evaluation Template](https://stu.instructure.com/courses/43967/files/3410724/download?download_frd=1) to:
1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
2. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
| | |
| — | — |
| **S =** | Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS) |
| **O =** | Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam |
| **A =** | Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes |
| **P =** | Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up |
**## psychsoapnote.template.docx**
**Psychiatric SOAP Note Template**
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
**HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
**SI/HI:** _______________________________________________________________________________
**Sleep:**_________________________________________
**Appetite:**\_\_\______________________
**Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________
**Current perception of Health**: Excellent Good Fair Poor
**Psychiatric History:**
**_Inpatient hospitalizations:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_Outpatient psychiatric treatment:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_Detox/Inpatient substance treatment:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_History of suicide attempts and/or self injurious behaviors:_**\_\_\__________________________________
**Past Medical History**
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
**Past Surgical History**\_\_\_________________________________________________________
**_Current psychotropic medications:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_Current prescription medications:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_OTC/Nutritionals/Herbal/Complementary therapy:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_Substance use_** _:_(alcohol, marijuana, cocaine, caffeine, cigarettes)
| | | | |
| — | — | — | — |
| **_Substance_** | **_Amount_** | **_Frequency_** | **_Length of Use_** |
| | | | |
| | | | |
| | | | |
| | | | |
**Family Psychiatric History:** _____________________________________________________
**Social History**
**Lives**: Single family House/Condo/ with stairs: ___________
**Marital Status**:________
**Education**:____________________________
**Employment Status**: ______
**Current/Previous occupation type**: _________________
**Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________
**Sexual Orientation:** _______ Sexual Activity: ____
**Contraception Use**: ____________
**Family Composition:** Family/Mother/Father/Alone
**: _____________________________**
**Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________**
**\_\_\______________________________________________________________________**
**Health Maintenance**
**Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____**
**Exposures:**
**Immunization HX:**
**Review of Systems:**
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
**Physical Exam**
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
**percentile**) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
**Mental Status Exam**
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
****Significant Data/Contributing Dx/Labs/Misc.****
****Plan:****
****Differential Diagnoses****
****1.****
****2.****
****Principal Diagnoses****
****1.****
****2.****
****Plan****
****Diagnosis #1****
****Diagnostic Testing/Screening:****
****Pharmacological Treatment:****
****Non-Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Diagnosis #2****
****Diagnostic Testingg/Screenin:****
****Pharmacological Treatment:****
****Non-Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Signature (with appropriate credentials): __________________________________________****
****Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________****
****DEA#: 101010101 STU Clinic LIC# 10000000****
****Tel: (000) 555-1234 FAX: (000) 555-12222****
**Patient Name: (Initials)______________________________ Age ___________**
**Date: _______________**
****RX ______________________________________****
****SIG:****
****Dispense**: ___________**
****Refill:** _________________**
****No Substitution****
****Signature:** ____________________________________________________________**
****Rev. 10162021 LM****
**## psychsoapnote.template.docx**
**Psychiatric SOAP Note Template**
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
**HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
**SI/HI:** _______________________________________________________________________________
**Sleep:**_________________________________________
**Appetite:**\_\_\______________________
**Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________
**Current perception of Health**: Excellent Good Fair Poor
**Psychiatric History:**
**_Inpatient hospitalizations:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_Outpatient psychiatric treatment:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_Detox/Inpatient substance treatment:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_History of suicide attempts and/or self injurious behaviors:_**\_\_\__________________________________
**Past Medical History**
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
**Past Surgical History**\_\_\_________________________________________________________
**_Current psychotropic medications:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_Current prescription medications:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_OTC/Nutritionals/Herbal/Complementary therapy:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_Substance use_** _:_(alcohol, marijuana, cocaine, caffeine, cigarettes)
| | | | |
| — | — | — | — |
| **_Substance_** | **_Amount_** | **_Frequency_** | **_Length of Use_** |
| | | | |
| | | | |
| | | | |
| | | | |
**Family Psychiatric History:** _____________________________________________________
**Social History**
**Lives**: Single family House/Condo/ with stairs: ___________
**Marital Status**:________
**Education**:____________________________
**Employment Status**: ______
**Current/Previous occupation type**: _________________
**Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________
**Sexual Orientation:** _______ Sexual Activity: ____
**Contraception Use**: ____________
**Family Composition:** Family/Mother/Father/Alone
**: _____________________________**
**Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________**
**\_\_\______________________________________________________________________**
**Health Maintenance**
**Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____**
**Exposures:**
**Immunization HX:**
**Review of Systems:**
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
**Physical Exam**
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
**percentile**) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
**Mental Status Exam**
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
****Significant Data/Contributing Dx/Labs/Misc.****
****Plan:****
****Differential Diagnoses****
****1.****
****2.****
****Principal Diagnoses****
****1.****
****2.****
****Plan****
****Diagnosis #1****
****Diagnostic Testing/Screening:****
****Pharmacological Treatment:****
****Non-Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Diagnosis #2****
****Diagnostic Testingg/Screenin:****
****Pharmacological Treatment:****
****Non-Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Signature (with appropriate credentials): __________________________________________****
****Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________****
****DEA#: 101010101 STU Clinic LIC# 10000000****
****Tel: (000) 555-1234 FAX: (000) 555-12222****
**Patient Name: (Initials)______________________________ Age ___________**
**Date: _______________**
****RX ______________________________________****
****SIG:****
****Dispense**: ___________**
****Refill:** _________________**
****No Substitution****
****Signature:** ____________________________________________________________**
****Rev. 10162021 LM****
**## soapnotemodule3instructuons.docx**
**Step 1:** You will use the
[Graduate Comprehensive Psychiatric Evaluation Template](https://stu.instructure.com/courses/43967/files/3410724?wrap=1) [Download Graduate Comprehensive Psychiatric Evaluation Template](https://stu.instructure.com/courses/43967/files/3410724/download?download_frd=1) to:
1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
2. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
| | |
| — | — |
| **S =** | Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS) |
| **O =** | Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam |
| **A =** | Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes |
| **P =** | Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up |
**## psychsoapnote.template.docx**
**Psychiatric SOAP Note Template**
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
**HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
**SI/HI:** _______________________________________________________________________________
**Sleep:**_________________________________________
**Appetite:**\_\_\______________________
**Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________
**Current perception of Health**: Excellent Good Fair Poor
**Psychiatric History:**
**_Inpatient hospitalizations:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_Outpatient psychiatric treatment:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_Detox/Inpatient substance treatment:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_History of suicide attempts and/or self injurious behaviors:_**\_\_\__________________________________
**Past Medical History**
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
**Past Surgical History**\_\_\_________________________________________________________
**_Current psychotropic medications:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_Current prescription medications:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_OTC/Nutritionals/Herbal/Complementary therapy:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_Substance use_** _:_(alcohol, marijuana, cocaine, caffeine, cigarettes)
| | | | |
| — | — | — | — |
| **_Substance_** | **_Amount_** | **_Frequency_** | **_Length of Use_** |
| | | | |
| | | | |
| | | | |
| | | | |
**Family Psychiatric History:** _____________________________________________________
**Social History**
**Lives**: Single family House/Condo/ with stairs: ___________
**Marital Status**:________
**Education**:____________________________
**Employment Status**: ______
**Current/Previous occupation type**: _________________
**Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________
**Sexual Orientation:** _______ Sexual Activity: ____
**Contraception Use**: ____________
**Family Composition:** Family/Mother/Father/Alone
**: _____________________________**
**Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________**
**\_\_\______________________________________________________________________**
**Health Maintenance**
**Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____**
**Exposures:**
**Immunization HX:**
**Review of Systems:**
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
**Physical Exam**
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
**percentile**) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
**Mental Status Exam**
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
****Significant Data/Contributing Dx/Labs/Misc.****
****Plan:****
****Differential Diagnoses****
****1.****
****2.****
****Principal Diagnoses****
****1.****
****2.****
****Plan****
****Diagnosis #1****
****Diagnostic Testing/Screening:****
****Pharmacological Treatment:****
****Non-Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Diagnosis #2****
****Diagnostic Testingg/Screenin:****
****Pharmacological Treatment:****
****Non-Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Signature (with appropriate credentials): __________________________________________****
****Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________****
****DEA#: 101010101 STU Clinic LIC# 10000000****
****Tel: (000) 555-1234 FAX: (000) 555-12222****
**Patient Name: (Initials)______________________________ Age ___________**
**Date: _______________**
****RX ______________________________________****
****SIG:****
****Dispense**: ___________**
****Refill:** _________________**
****No Substitution****
****Signature:** ____________________________________________________________**
****Rev. 10162021 LM****
**## soapnotemodule3instructuons.docx**
**Step 1:** You will use the
[Graduate Comprehensive Psychiatric Evaluation Template](https://stu.instructure.com/courses/43967/files/3410724?wrap=1) [Download Graduate Comprehensive Psychiatric Evaluation Template](https://stu.instructure.com/courses/43967/files/3410724/download?download_frd=1) to:
1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
2. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
| | |
| — | — |
| **S =** | Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS) |
| **O =** | Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam |
| **A =** | Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes |
| **P =** | Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up |
**## psychsoapnote.template.docx**
**Psychiatric SOAP Note Template**
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
**HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
**SI/HI:** _______________________________________________________________________________
**Sleep:**_________________________________________
**Appetite:**\_\_\______________________
**Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________
**Current perception of Health**: Excellent Good Fair Poor
**Psychiatric History:**
**_Inpatient hospitalizations:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_Outpatient psychiatric treatment:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_Detox/Inpatient substance treatment:_**
| | | | |
| — | — | — | — |
| **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
| | | | |
| | | | |
**_History of suicide attempts and/or self injurious behaviors:_**\_\_\__________________________________
**Past Medical History**
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
**Past Surgical History**\_\_\_________________________________________________________
**_Current psychotropic medications:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_Current prescription medications:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_OTC/Nutritionals/Herbal/Complementary therapy:_**
\_\_\_______________________________________ ________________________________
\_\_\_______________________________________ ________________________________
**_Substance use_** _:_(alcohol, marijuana, cocaine, caffeine, cigarettes)
| | | | |
| — | — | — | — |
| **_Substance_** | **_Amount_** | **_Frequency_** | **_Length of Use_** |
| | | | |
| | | | |
| | | | |
| | | | |
**Family Psychiatric History:** _____________________________________________________
**Social History**
**Lives**: Single family House/Condo/ with stairs: ___________
**Marital Status**:________
**Education**:____________________________
**Employment Status**: ______
**Current/Previous occupation type**: _________________
**Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________
**Sexual Orientation:** _______ Sexual Activity: ____
**Contraception Use**: ____________
**Family Composition:** Family/Mother/Father/Alone
**: _____________________________**
**Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________**
**\_\_\______________________________________________________________________**
**Health Maintenance**
**Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____**
**Exposures:**
**Immunization HX:**
**Review of Systems:**
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
**Physical Exam**
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
**percentile**) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
**Mental Status Exam**
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
****Significant Data/Contributing Dx/Labs/Misc.****
****Plan:****
****Differential Diagnoses****
****1.****
****2.****
****Principal Diagnoses****
****1.****
****2.****
****Plan****
****Diagnosis #1****
****Diagnostic Testing/Screening:****
****Pharmacological Treatment:****
****Non-Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Diagnosis #2****
****Diagnostic Testingg/Screenin:****
****Pharmacological Treatment:****
****Non-Pharmacological Treatment:****
****Education:****
****Referrals:****
****Follow-up:****
****Anticipatory Guidance:****
****Signature (with appropriate credentials): __________________________________________****
****Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________****
****DEA#: 101010101 STU Clinic LIC# 10000000****
****Tel: (000) 555-1234 FAX: (000) 555-12222****
**Patient Name: (Initials)______________________________ Age ___________**
**Date: _______________**
****RX ______________________________________****
****SIG:****
****Dispense**: ___________**
****Refill:** _________________**
****No Substitution****
****Signature:** ____________________________________________________________**
****Rev. 10162021 LM****
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