In the field of pediatric psychology, accurate and detailed clinical documentation is essential for effective patient care. The Comprehensive Interventional and General Psychiatry Intake document serves as a cornerstone for understanding a patient's mental health status and planning appropriate interventions. Here's a step-by-step guide on how to write and format this document using a structured template.

Chief Complaint

The chief complaint is a concise statement describing the primary issue that brings the patient to seek care. For instance, "I feel like I'm constantly on edge and can't focus on anything," reports the patient. This statement should be the patient's own words to capture their personal experience.

History of Present Illness (HPI)

The HPI provides a narrative of the patient's current condition. In this example, a 15-year-old male presents with increasing anxiety and difficulty concentrating over six months. Details such as the patient's struggles at school, reactions from family members, and any precipitating factors should be included. The HPI should offer a comprehensive view of the patient's recent experiences and symptoms.

Psychiatric Review of Systems

This section systematically reviews various psychiatric symptoms. Document both positive and negative findings, such as reports of low energy and difficulty sleeping, and denials of manic episodes or psychotic symptoms. This comprehensive review helps in understanding the patient's mental health status across different domains.

Past Psychiatric History

Detail the patient's previous psychiatric diagnoses, treatments, and any history of hospitalizations or higher levels of care. For example, the patient has a history of Generalized Anxiety Disorder diagnosed at age 14 and a trial of sertraline that was discontinued due to side effects.

Substance Use History

Record any current or past substance use. In this case, the patient denies any substance use, which is important for assessing risk factors and treatment planning.

Past Medical and Surgical History

Include any relevant medical conditions or surgeries. Here, the patient has a history of asthma controlled with an inhaler, with no surgical history.

Social and Family History

Provide context about the patient's living situation, family dynamics, and any relevant family medical history. The patient lives with both parents and a sister, and the mother has a history of anxiety, which can inform treatment approaches.

Current Medications and Allergies

List all current medications and any known allergies. The patient is currently taking albuterol for asthma and has no known drug allergies.

Mental Status Exam

This examination assesses the patient's appearance, behavior, speech, mood, thought processes, and cognition. For example, the patient is well-groomed, cooperative, and shows a stressed mood with preoccupation about academic performance.

Rating Scales, Labs, and Studies

Include any relevant diagnostic scores or laboratory results. The PHQ-9 score of 8 indicates mild depression, providing quantitative data to support the clinical assessment.

Clinical Global Impressions

Provide a global assessment of the patient's severity and improvement. A CGI-S score of 4 indicates the patient is moderately ill, with clear symptoms impacting school performance.

Assessment

Summarize the patient's condition and contributing factors. For example, a 15-year-old male with Generalized Anxiety Disorder experiencing academic difficulties due to school stress and peer pressure.

Risk Assessment

Evaluate any risks to the patient or others. In this scenario, there are no current risks, and protective factors include a supportive family and ongoing therapy.

Medication and Somatic Interventions

Consider potential medications or interventions. Here, starting a low-dose SSRI is considered if symptoms persist.

Psychotherapeutic Interventions

Outline ongoing or planned therapy approaches. Continuing cognitive-behavioral therapy focusing on anxiety management and study skills is recommended.

Plan

Clearly state the next steps in treatment. For this patient, continuing current therapy and monitoring symptoms with potential medication options if no improvement is noted.

Collaboration and Safety Plan

Include any collaborative efforts with other professionals and safety measures. The patient is also seeing a school counselor, and a safety plan is in place for emergencies.

AI medical scribes like Notis AI Medical Scribe can revolutionize the documentation process in pediatric psychology. By automating the creation of structured SOAP notes, Notis significantly reduces the time spent on administrative tasks. This allows healthcare providers to focus more on patient care and less on paperwork.

Notis offers features such as voice-to-text transcription, high accuracy, and easy integration through platforms like WhatsApp. With the ability to support multiple languages and provide comprehensive documentation, Notis enhances the efficiency and accuracy of patient documentation. This is particularly beneficial in specialties like pediatric psychology, where detailed and timely documentation is crucial for effective patient care.

In summary, mastering clinical documentation in pediatric psychology involves understanding each section of the Comprehensive Interventional and General Psychiatry Intake document. AI medical scribes like Notis provide a powerful tool to streamline this process, ultimately improving patient care and reducing clinician burnout.