Comprehensive Psychiatric SOAP w/ E/M Coding

[INCLUDE A VISIT TITLE that is a few word summary of the theme of the visit. State what med was changed if applicable] Chief Complaint: - [Reason for visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) HPI/Interim History: [Discuss interim history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Include a section on substance use if any was mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Include any mention of how the symptoms are functionally impairing (or not) or contributing to the need for disability or a leave of absence (if applicable). If functioning is good and improved also describe that] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Psychotherapy and Psychotherapeutic Interventions: - [State amount spent was over 16 minutes and general theme] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Specific topics discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Therapeutic interventions used and their impact] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Target symptoms: [List target symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Progress towards treatment goals: [Describe progress] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Techniques used: [List techniques used, such as mentalization-based treatment, CBT, DBT] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Current Medications Discussed (see DrFirst for complete list): - [Medication name, dosage, frequency]: [Efficacy, side effects, adherence] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Any changes or adjustments to medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Pertinent Past Medications and Psychiatric Treatments: - [Past medication trials and details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Other past psychiatric treatments and details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Past psychiatric hospitalizations or higher levels of care] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Objective: Mental Status Exam - General Appearance and Behavior: [Description] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Motor abnormalities: [Description or "no abnormal motor movements"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Speech: [Description or "Normal rate, rhythm and prosody"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Eye contact: [Description] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Affect: [Description of congruence and general sentiment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Mood: [Patient's own words or "neutral"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Thought content: [Notable themes, future orientation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Thought process: [Description of abnormalities or "linear and goal-directed"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Cognition: [Description or "grossly intact attention and memory"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Orientation: [Description or "alert and oriented"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - SI, HI, Violent ideation: [Presence or absence] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Insight and judgment: [Description of degree of insight and judgment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) DATA - [Rating scales completed and scores] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Labs or other studies referenced and details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Clinical Global Impressions: - CGI-S (Severity): [Score] ([Description]) - [Reason for score] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - CGI-I (Improvement): [Score] ([Description]) - [Reason for score] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Assessment and Plan: - [Diagnosis 1]: [Summary of condition, progress, and plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Diagnosis 2]: [Summary of condition, progress, and plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Additional diagnoses as needed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Overall: [Summary of patient's overall status and any changes to treatment plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Z codes: [Please include any suggested Z codes (full codes) for Social determinants of health or other pertinent Z codes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Risk Assessment and Plan: - [Concerns or changes in risk to self or others (suicidality, self-harm, violence)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Protective factors: [List protective factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Risk factors: [List risk factors and note if modifiable or static] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Documentation of risk management or escalation of level of care] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Patient is aware of how to reach me, covering clinician, and members of the treatment team in case of emergency. She understands that email is for non-urgent logistical matters only, such as scheduling. She has been advised that text messages in the middle of the night are unlikely to be heard, so calling is the most reliable way to reach me in urgent situations. Olivia has been advised to call 911 or go to the nearest emergency room should any acute safety concerns arise while awaiting a call back. She is also aware of the 988 Crisis Line for additional support. Medication and Interventions Plan: - [Detailed treatment plan regarding medications or interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Discussion of risks, benefits, side effects, and alternatives] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Research studies mentioned regarding specific treatments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Tests and Studies: [Describe any tests or studies ordered] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Collaboration and Psychoeducation Plan: - [Other mental health and medical treaters patient is seeing or referred to] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Family collaboration, if significant] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Collateral information gathered or planned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Psychoeducation provided, if any] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medical Decision Making: - [Elements of medical decision making present in the visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - E/M Code: [Suggested E/M code] ([New or established patient], [Complexity level]) - [Reason for code selection] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Interactive Complexity: [Rationale for interactive complexity, if applicable (if not, leave section out)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Followup: - [Next appointment date and time, if scheduled, or patient's plan to self-schedule] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Discharge plan, if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)