Preparation of report of patient's psychiatric status, history, treatment, or progress (other than for legal or consultative purposes) for other individuals, agencies, or insurance carriers
CPT4 code
Name of the Procedure:
Preparation of Report of Patient's Psychiatric Status, History, Treatment, or Progress
Common name(s): Psychiatric Status Report, Psychiatric Evaluation Report
Technical/Medical term: Psychiatric Status and Progress Report
Summary
A detailed written document summarizing a patient's psychiatric condition, treatment history, and progress. It is shared with other healthcare professionals, agencies, or insurance carriers to provide comprehensive information about the patient's mental health status.
Purpose
The report addresses the need to communicate detailed psychiatric information to parties involved in the patient's care or coverage. It aims to provide an accurate and thorough overview of the patient's mental health status, treatment history, and progress to aid in ongoing treatment decisions, support requests, or insurance claims.
Indications
- Ongoing psychiatric treatment requiring updated evaluations.
- Coordination of care among different healthcare providers.
- Providing necessary documentation for insurance claims or coverage.
- Conditions such as anxiety disorders, mood disorders, psychotic disorders, or any mental health issues requiring detailed reporting.
Preparation
- The patient may need to fill out self-assessment questionnaires.
- No specific physical preparation like fasting or medication adjustments is generally required.
- Diagnostic tests, such as psychological assessments, may be conducted prior to compiling the report.
Procedure Description
- History Collection: Gathering comprehensive history through patient interviews, family reports, and reviewing past medical records.
- Clinical Evaluation: Conducting a thorough psychiatric evaluation, including mental status examination and possibly psychometric tests.
- Collaboration: Consulting with other healthcare providers involved in the patient's care.
- Report Drafting: Writing a detailed report summarizing the patient's psychiatric history, current status, treatment, and progress.
- Review: Ensuring accuracy and completeness of the information before finalizing the report.
No tools, anesthesia, or sedation are required for this non-invasive, documentation process.
Duration
The overall process, including interviews and evaluations, typically takes a few hours spread over several days, with the actual report preparation taking a couple of hours.
Setting
The procedure is usually performed in a clinical office setting, such as a psychiatrist's office or mental health clinic.
Personnel
- Psychiatrists
- Clinical Psychologists
- Licensed Mental Health Professionals
- Nursing staff (if needed for patient support and information gathering)
Risks and Complications
- Minimal risk, as the procedure is non-invasive.
- Potential for minor discomfort during in-depth interviews.
- Risk of miscommunication or omission if complete information is not provided.
Benefits
- Provides a comprehensive overview for coordinated care.
- Facilitates informed treatment decisions and insurance approvals.
- Enhances understanding of the patient's progress and needs.
Recovery
- No physical recovery required.
- Patients may need a follow-up visit to discuss the report's content and future treatment plans.
Alternatives
- Verbal communication of the patient's status during interdisciplinary meetings.
- Digital health records shared amongst providers when appropriate.
- Summary notes or shorter reports.
Patient Experience
- Generally involves multiple interviews and assessments.
- Patients may feel emotional sharing personal and sensitive information.
- Ensured comfort with supportive communication and appropriate breaks during the process.