Psychiatric History & Progress Note Templates

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About the Psychiatric History Template
About the Visit Progress Note Template
About the Visit Face Sheet
License Agreements for Use
Training
Translations and Linguistic Validation
How to Cite


About the Psychiatric History Template

The psychiatric history template is designed to provide the clinician with a systematic approach to documenting important information at the initial screening or consultation visit.  It reduces the likelihood of the clinician overlooking items of importance.  The psychiatric history template contains sections on:

  • patient demographic information
  • identifying data
  • presenting problem(s)
  • onset and course of presenting problem
  • structured diagnostic interview summary
  • past psychiatric history
  • psychiatric medications (current & past)
  • suicide / self – harm history
  • history of violence or homicidality
  • past medical history
  • current health practices
  • family psychiatric / medical history
  • social history
  • mental status examination
  • disability / functional impairment
  • a free field area area for comments
  • diagnosis
  • treatment plan
  • a summary overview front page for the psychiatric history template

Use of a structured psychiatric history template affords better healthcare protection for the patient and better medico-legal protection for the clinician.

For any scientific questions relating to the Psychiatric History Template, contact David V Sheehan MD MBA directly by email at davidvsheehan@gmail.com

To view a copy of the Psychiatric History Template (click here)

To purchase and download a copy of the Psychiatric History Template (click here)


About the Visit Progress Note Template

The visit progress note template helps to maintain consistency, quality control, and to systematize the collection of critical information for mental health follow up care visits.  The psychiatric visit progress note template is designed to provide the clinician with a systematic approach to documenting important information at each follow up visit.  The visit progress note template contains sections on:

  • medication & dosage
  • adverse reaction(s)
  • psychometric scales used with visit specific scores
  • compliance with treatment plan
  • clinical & behavioral symptoms and progress of treatment
  • psychosocial stressors
  • concurrent illnesses
  • evidence of psychotherapeutic process
  • medication prescribed
  • treatment intervention & instructions to patient
  • treatment plan, objectives, anticipated benefits, & estimated time to meet treatment goals
  • summary comments
  • plan for follow up visit

It reduces the likelihood of the clinician overlooking items of importance.  This affords better healthcare protection for the patient and better medico-legal protection for the clinician.

For any scientific questions relating to the Visit Progress Note Template, contact David V Sheehan MD MBA directly by email at davidvsheehan@gmail.com

To view a copy of the Visit Progress Note Template (click here)

To purchase and download a copy of the Visit Progress Note Template (click here)


About the Visit Face Sheet

To focus the clinician’s attention in addressing the patient’s needs, questions, and problems at each visit, it is prudent to provide a visit face sheet for the patient to complete prior to the visit.  The sample face sheet asks the patient to identify the main needs, questions, and problems they want addressed at this visit.  For example, the clinician may assume that the patient has come for a follow up visit to monitor their response to an antidepressant treatment.  However, the patient may be coming to the visit because they want the clinician to complete a form to help them get food stamps and to get them to write a report for their divorce lawyer, so that they will not lose custody of their children on mental health grounds.  The patient may wait bring up these two additional requests at the very end of the allotted time for the visit. If the clinician had known about these issues from the start, they would have allocated the visit time more efficiently to accommodate these requests.

The visit face sheet can assist the patient in communicating their needs for the visit to their clinician at the beginning of the visit.  This assists the clinician in better managing their time with the patient.

For any scientific questions relating to the Visit Face Sheet, contact David V Sheehan MD MBA directly by email at davidvsheehan@gmail.com

To view a copy of the Visit Face Sheet (click here)

To purchase and download a copy of the Visit Face Sheet (click here)


License Agreements for Use

To license the Psychiatric History Template for Use in a Study or for a Healthcare System:

  • To License the Paper / PDF Version for Use in a Research Study with Grants >$50,000 or for a Pharmaceutical Company – There is a charge of $2 per single administration (not per patient enrolled). The amount is payable in full before study initiation.  (click here to download this license agreement)
  • To License the Paper / PDF Version for Use in a Research Study with Grants <$50,000 – The Psychiatric History Template is available free of charge to undergraduate and graduate students and for academic colleagues for educational use and for use in a small study with less than $50,000 funding as long as it is properly cited and proper copyright attribution is given on any study documents.  (click here to download this license agreement)
  • To License the Paper / PDF Version for Use in a Healthcare System – There is a charge of $2 per single administration (not per patient). The amount is payable in full before use.  (click here to download this license agreement)
  • To LicenseComputerized / Electronic / Mobile or Tablet App Version for Use – contact akozsuch@nviewhealth.com

To license the Visit Progress Note Template for Use in a Study or for a Healthcare System:

  • To License the Paper / PDF Version for Use in a Research Study with Grants >$50,000 or for a Pharmaceutical Company – There is a charge of $1 per single administration (not per patient enrolled). The amount is payable in full before study initiation.  (click here to download this license agreement)
  • To License the Paper / PDF Version for Use in a Research Study with Grants <$50,000 – The Visit Progress Note Template is available free of charge to undergraduate and graduate students and for academic colleagues for educational use and for use in a small study with less than $50,000 funding as long as it is properly cited and proper copyright attribution is given on any study documents.  (click here to download this license agreement)
  • To License the Paper / PDF Version for Use in a Healthcare System – There is a charge of $1 per single administration (not per patient). The amount is payable in full before use.  (click here to download this license agreement)
  • To LicenseComputerized / Electronic / Mobile or Tablet App Version for Use – contact akozsuch@nviewhealth.com

To license the Visit Face Sheet for Use in a Study or for a Healthcare System:

  • To License the Paper / PDF Version – There is no charge per single administration for the paper / PDF version as long as every administered copy includes the copyright statement and permissions contact information included in the Visit Face Sheet’s footer and it is properly cited in any publication (see Sheehan & Giddens 2015, and Sheehan & Giddens 2016 below in How to Cite the Visit Face Sheet).

Training

For information about training on the Psychiatric History Template, the Visit Progress Note Template, or the Visit Face Sheet, please contact: davidvsheehan@gmail.com


Translations and Linguistic Validation

Mapi (http://www.mapigroup.com) is the official translation and linguistic validation service for all variants of the Psychiatric History Template, the Visit Progress Note Template, or the Visit Face Sheet.

MAPI Language Services is the exclusive coordinating center to ensure the production of consistent and conceptually equivalent translations of the Psychiatric History Template, the Visit Progress Note Template, or the Visit Face Sheet and to provide linguistic validation and certification of these translations and should be contacted directly for this purpose.  MAPI Language Services may charge its own usual fees for this work.

Marie-Sidonie Edieux

MAPI Research Trust

27 Rue de la Villette

69003 Lyon France

PROinformation@mapigroup.com

tel: +33 (0)4 72 13 66 67

fax: +33 (0)4 72 13 66 68/ :+33 (0)4 72 13 69 50


How to Cite

Use the following citation in referencing the Psychiatric History Template, the Visit Progress Note Template, or the Visit Face Sheet:

  1. Sheehan DV, Giddens JM. (2016). Suicidality Assessment and Documentation for Healthcare Providers: A Brief, Practical Guide. (1st ed.). Tampa, FL: Harm Research Press. April 2016. (Available from: http://HarmResearch.org) ISBN: 978-0-9969729-1-8