Review 1 de-identified intake note for a patient with either ADHD or bipolar. Please ensure your note includes the following:
Chief Complaint
HPI
Risk Assessment
Medical & Substance History
Mental Status Exam
Treatment/Diagnosis
Clinical quality is extremely important . One way we assess clinical quality is to review a sample of clinical notes to gain insight into your clinical thought process and billing/coding practices. You are free to create an initial note in your typical template rather than sharing redacted patient notes if preferred.
Sample Answer
Sample Answer
De-Identified Intake Note
Patient ID: 001234
Date: [Insert Date]
Clinician: [Insert Clinician Name]
Facility: [Insert Facility Name]
Chief Complaint
The patient presents with difficulties in attention and mood regulation, expressing concern about their inability to focus on tasks and frequent mood swings.
HPI (History of Present Illness)
The patient is a 12-year-old male who has been experiencing symptoms consistent with Attention Deficit Hyperactivity Disorder (ADHD) and mood instability for the past year. According to the mother, he has significant trouble concentrating in school, often daydreaming during lessons, and struggles to complete homework assignments. His grades have dropped from A’s to C’s over the last two semesters. The mother reports that the patient often seems restless and fidgets excessively, which affects his ability to sit still during classes.
In terms of mood, the patient experiences rapid mood swings, transitioning from irritability and anger to periods of sadness. These shifts can occur several times a day and are often triggered by school-related stressors or conflicts with peers. The mother notes that he has had episodes of emotional outbursts, where he becomes verbally aggressive, particularly when asked to complete tasks he finds boring. There is no reported history of suicidal ideation or self-harm.
The patient has no previous psychiatric treatment history and has never been on medication for these issues. Family history reveals that his father has a history of ADHD and his maternal uncle has been diagnosed with bipolar disorder.
Risk Assessment
– Suicidal Ideation: Denies any thoughts of self-harm or suicide.
– Homicidal Ideation: Denies any thoughts of harming others.
– Substance Use: Denies use of alcohol, cannabis, or other drugs.
– Safety Concerns: No current safety concerns reported; however, the patient exhibits impulsive behavior that requires monitoring.
Medical History
– Chronic Conditions: None reported.
– Medications: None.
– Allergies: No known drug allergies (NKDA).
Substance History
– Alcohol Use: Denies.
– Tobacco Use: Denies.
– Recreational Drugs: Denies.
Mental Status Exam
– Appearance: Well-groomed, appropriate attire for age.
– Behavior: Cooperative but appears restless throughout the session.
– Speech: Normal rate and tone; occasionally tangential.
– Mood/Affect: Mood described as “frustrated”; affect is labile, shifting from frustration to sadness.
– Thought Process: Logical but occasionally distracted; difficulty maintaining focus on questions.
– Thought Content: No delusions or hallucinations; denies suicidal/homicidal ideation.
– Cognition: Alert and oriented to person, place, time; able to recall recent events but struggles with attention and concentration.
– Insight/Judgment: Limited insight into behavioral issues; judgment appears intact regarding personal safety.
Treatment/Diagnosis
Diagnosis:
1. Attention Deficit Hyperactivity Disorder (ADHD), Combined Presentation (F90.2)
2. Mood Disorder Not Otherwise Specified (NOS) (F39) – pending further evaluation.
Treatment Plan:
1. Referral for psychological testing to confirm ADHD diagnosis and assess for possible mood disorder.
2. Educate the patient and family regarding ADHD, including strategies for managing symptoms.
3. Discuss the possibility of starting a trial of a stimulant medication if ADHD is confirmed.
4. Recommend behavioral therapy focusing on coping strategies for emotional regulation and attention management.
5. Schedule a follow-up appointment in 4 weeks to reassess symptoms and response to any interventions initiated.
Signature:
[Clinician Name], [Clinician Credentials]
[Date]
This note reflects the necessary components for a comprehensive intake assessment while ensuring clinical quality through thorough documentation of the patient’s presenting issues, history, and mental status exam.
