Antipsychotic Monitoring Note (Metabolic/EPS)

Date/Time: [Encounter date and time]

Patient: [Patient name or identifier]

Encounter Type: [in-person / telehealth video / phone]

Clinician: [Clinician name and credentials]

Reason for Visit: [routine monitoring / post-dose change / abnormal results follow-up]

Current Antipsychotic Regimen

• [Generic antipsychotic name] — [formulation: oral / LAI / ODT], [current dose and frequency]; Start: [start date or approximate]; Last dose change: [date or "none recent"]; Adherence: [adherent / partial / nonadherent] — [adherence barriers if present]
(Repeat for each active antipsychotic.)
• Other dopamine-blocking agents: [agent name(s) with dose/frequency, if any] (Include antiemetics or other agents relevant to EPS risk attribution; omit if none.)

Indication & Interval Response

Indication: [Working diagnosis] — [target symptoms or functional goals for antipsychotic therapy]

Interval response: [improved / unchanged / worsened] — [brief supporting detail]

Patient-Reported Side Effects

• Metabolic: [endorsed metabolic symptoms with brief qualifiers] (Screen for weight/appetite changes, polyuria/polydipsia, fatigue, exercise intolerance.)
• EPS: [endorsed EPS symptoms with brief qualifiers] (Screen for restlessness, stiffness, tremor, slowed movement, muscle spasms, involuntary movements.)
• Other: [other endorsed tolerability concerns] (Include sedation, orthostasis, anticholinergic effects, hyperprolactinemia symptoms as relevant; omit if none.)

Monitoring Data

Metabolic Trend

• Weight/BMI: [Baseline value (date)] → [Current value (date)] [flag if clinically meaningful change] (If telehealth, note source and limitations. If missing, state reason and plan.)
• Blood Pressure: [Baseline (date)] → [Current (date)] (If missing, state reason and plan.)
• Glycemic: [Fasting glucose or HbA1c] — [Baseline value (date)] → [Current value (date)] [flag if prediabetes/diabetes range] (If missing, state reason and plan.)
• Lipid panel: [Baseline values (date)] → [Current values (date)] [brief interpretation if abnormal] (If missing, state reason and plan.)

EPS/TD Assessment

[Clinical observation findings for akathisia, parkinsonism, dystonia, and involuntary movements] (If assessment not performed or limited, state reason. Do not document absence of TD unless movement assessment was actually performed.)

• AIMS: [performed (date) / due / deferred] — [total score, items of concern, patient awareness/distress, factors affecting interpretation] (If deferred, state reason and when it will be completed. Omit if not due.)

Assessment & Plan

Primary Psychiatric Diagnosis

Status: [stable / improving / worsening] — [brief supporting evidence]

• [Plan related to primary diagnosis]

Antipsychotic Management

Status: [adequate response / partial response / inadequate response / adverse effects limiting]

Risk-Benefit Summary: [Benefits observed] vs [risks discussed with patient]. [Patient preferences and shared decision reached].

• Medication Plan: [continue / adjust dose / switch / discontinue] — [rationale and any adjunctive interventions]

Metabolic Status

Status: [stable / improving / worsening / at-risk] — [key supporting data]

• [Metabolic management plan] (Omit if no active concerns or interventions.)

EPS/TD Status

Status: [no EPS / EPS present / TD concern / not assessed] — [supporting findings] (Do not state "no TD" unless assessment was performed.)

• [EPS/TD management plan] (Omit if no active concerns or interventions.)

Monitoring Schedule

• Reviewed today: [parameters reviewed with dates]
• Ordered today: [tests/orders placed]
• Next due: Weight/BP — [date/interval]; Glycemic — [date/interval]; Lipids — [date/interval]; AIMS — [date/interval]
• Next monitoring visit: [timeframe]

Additional Elements

• Clozapine: Most recent ANC [value] ([date]); Next ANC due [date]; Constipation [present / absent]; Infection symptoms [present / absent] (Include only if patient is on clozapine.)
• QTc/ECG: Most recent QTc [value] ([date]); Plan for repeat [date/criteria] (Include only if QTc monitoring is indicated.)
• LAI: Last injection [date, dose, site]; Next due [date] (Include only if patient receives LAI.)