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Mental Status Exam

Behavior cooperative check

Affect appropriate check

Insight good check

No exceptions noted

Note Transcript lock Signed

description

Progress note

Follow-up visit, 25 min

Interval History

Sleep improved on the current dose. Mood brighter week over week, energy not yet back to baseline.

Mental Status Exam

cooperative speech normal affect appropriate insight good denies SI/HI

Plan

Continue sertraline 100 mg daily. Supportive psychotherapy, 16 min. Follow-up in 4 weeks.

Suggested 99214 90833

To sign · 2

Recorded 24:06

Transcript

Clinician

How has the higher dose felt?

Patient

Sleeping through the night now.

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MDM Moderate

Problems addressed 1 chronic

Face-to-face 25 min

E/M + Add-On ready