Patient_id 4800 - date august 13, 2013

Patienttrac Outpatient Center
1818 Anystreet
Miami Beach, Florida 33140
Telephone (305) 555-1212
Facsimile (305) 555-1212
PROGRESS NOTE - BRIEF
PATIENT NAME
James Newpatient, Sr
MEDICAL RECORD NO.
SOCIAL SECURITY
999-99-9999
SECONDARY MRN
DATE OF BIRTH
September 01 , 1966
PROVIDER NAME
Louis Test, M.D.
VISIT DATE
August 13 , 2013
IDENTIFICATION
This is a 46 year old white divorced male who resides in Raleigh, North Carolina. He is currently
living alone.
CHIEF COMPLAINT
Mr. Newpatient presents to our office for follow up visit.
CURRENT HISTORY
BEHAVIOR: James' behavior issues are primarily reported as inappropriate sexual behavior. The
duration is reported as > 6 months.
MOOD: James presents with a history of a manic mood type. He reports he has been for improving
for last few weeks. His symptoms are of a mild rated intensity level.
STRESSORS: James's current stressors include occupational. The stress level of this stressor is
reported as of mild intensity. He identifies specific issues, which include had a very good job offer.
He is very excited about the new opportunity. He intends to focus on his conduct at work and 'make
this work'
CURRENT MEDICATIONS
Mr. Newpatient's current medications are:
CYMBALTA 30 Quantity 1 CYMBALTA CAPSULE 30 MG QHS for 30 Days. Prescribed by
Louis Test, M.D. for depressed mood.
PAST HISTORY OF
Mr. Newpatient's previous psychotropic medications are:
MEDICATIONS
LEXAPRO TABLET 20 Quantity 1 LEXAPRO TABLET 20 MG QD for 30 Days. Prescribed by
Primary Care Provider for depressed mood.
XANAX .5 Quantity 1 XANAX TABLET .5 MG QD for 30 Days. Prescribed by Louis Test, M.D.
MENTAL STATUS
Mr. Newpatient is a 46 year old white male.
PATIENT APPEARS: appears to be younger than stated age.
REMARKABLE FEATURES: none.
ALERTNESS: alert.
APPEARANCE: well groomed.
NUTRITIONAL STATUS: well nourished.
HABITUS: average height.
OREINTATION: person(name), place, time, situation.
EYE CONTACT: good.
MOOD: euthymic, anxious.
AFFECT: full range.
THOUGHT PROCESS: goal directed.
JAMES NEWPATIENT, SR Medical Record No. 4800 Date of Birth: 09/01/1966 Visit Date August 13, 2013
THOUGHT CONTENT: logical.
INTELLIGENCE LEVEL: normal.
INSIGHT: good.
JUDGMENT: good.
FUND OF KNOWLEDGE: good.
SUICIDAL IDEATION: Mr. Newpatient denies the presence of suicidal ideation.
HOMICIDAL IDEATION: Mr. Newpatient denies the presence of homicidal ideation.
DIAGNOSIS
AXIS IV: James' current stressors include occupational. The stress level is reported as of mild
intensity. He had a very good job offer. He is very excited about the new opportunity. He intends to
focus on his conduct and 'make this work'.
PLAN AND RECOMMENDATIONS
EDUCATION
The importance of behavioral interventions reviewed.
We discussed doing a reality check of his thinking.
I have discussed the use of psychotropic medications and benzodiazepines and alcohol. Patient
verbalized full understanding about the risk and benefits of combining medication and alcohol.
INSTRUCTIONS
Continue current medications.
Carve out time for self.
Work on daily structure.
REVIEW OF MEDICATIONS
MEDICATION: 30 MG CYMBALTA CAPSULE CAPSULE, DELAYED RELEASE ORAL
Quantity 1 CYMBALTA CAPSULE 30 MG QHS for 30 Days Dispense: Refills: 0.
* PRESCRIBED BY: Louis Test, M.D.
* SIDE EFFECTS: none reported.
* EFFECTIVENESS: responding to medication.
* COMPLIANCE: compliant with medications.
* ACTION TAKEN: Continue.
* CURRENT STATUS: Continue.
MEDICATION ORDERS
ACTIVE MEDICATIONS
Patient is instructed to continue the following medications as directed:
* 30 MG CYMBALTA Quantity 1 CYMBALTA CAPSULE 30 MG QHS for 30 Days. Ordered by
Louis Test, M.D. for depressed mood.
FOLLOW-UP
Three weeks for Office E/M visit with Psychotherapy.
Louis Test, M.D.
JAMES NEWPATIENT, SR Medical Record No. 4800 Date of Birth: 09/01/1966 Visit Date August 13, 2013

Source: http://www.patienttracemr.com/downloads/Adult-Followup-Brief.pdf