Child & Adolescent Psychiatry Follow-Up Progress Note (Medication Management)

Date/Time: [date and time of encounter]

Patient: [full name, DOB]

Provider: [name, credentials]

Visit Type: Follow-Up Progress Note (Medication Management)

Setting/Modality: [in-person / telehealth]; [location]

Participants: [who was present] (Note if any portion was patient alone.)

Information Sources: [patient / parent-guardian(s) / collateral sources] (Note reliability concerns if relevant.)

Chief Complaint

[One-line reason for visit anchored to treatment focus] (Use patient or caregiver words when available.)

Interval History

[Narrative summary of the interval since last visit] (Include overall clinical trajectory; target symptom status with frequency, severity, and functional impact at home, school, and with peers; medication adherence including missed doses and barriers; medication response and side effects; relevant contextual factors such as sleep, appetite, school performance, family dynamics, and substance use when indicated. Incorporate rating scale data when used with scale name, score, date, and interpretation. Note interval events such as ED visits or hospitalizations. Attribute information to specific sources throughout. Omit domains not discussed unless safety-critical.)

Objective

Vitals/Growth: [weight, BMI, BP, HR as relevant] (Include when indicated for current medications. If not obtained, state why and plan to obtain.)

Labs/Monitoring: [relevant results with date and interpretation] (Omit if none pertinent.)

Mental Status Exam: (Document salient normals and all abnormalities; keep concise.)

• Appearance/Behavior: [appearance, grooming, motor activity, cooperation]
• Speech: [rate, volume, articulation]
• Mood/Affect: [patient-stated mood]; [observed affect including range, congruence, stability]
• Thought Process: [organization, coherence]
• Thought Content: [suicidal or homicidal ideation, obsessions, delusions]
• Perceptions: [hallucinations or other perceptual disturbances]
• Cognition: [orientation, attention]
• Insight/Judgment: [brief assessment]

Risk Assessment

• Suicidality: [direct assessment of suicidal ideation] (If present, document plan, intent, and means access.)
• Self-harm: [recent behaviors; relevant past history if updated]
• Aggression/Violence: [assessment if clinically relevant]
• Stressors/Protective Factors: [acute stressors]; [supports, coping, reasons for living]
• Overall Risk Level: [low / moderate / high] — [brief clinical rationale and disposition]
• Safety Measures: [means safety counseling; safety plan status; crisis resources; caregiver monitoring] (Include when risk is elevated.)

(If unable to complete risk assessment, document reason and immediate plan to address.)

Assessment

[Brief synthesis of current presentation and treatment response]

Active Problems:

• [Diagnosis/problem 1]: [improving / unchanged / worsening] — [supporting evidence]
• [Diagnosis/problem 2]: [improving / unchanged / worsening] — [supporting evidence]

(List problems in order of clinical importance. Update diagnoses only when clinically justified.)

Plan

Medications:

• [Medication, dose, route, frequency] — [continue / start / stop / adjust]: [rationale] (Include titration instructions, adherence plan, side effect mitigation, and return precautions as applicable. Document risk-benefit discussion and consent/assent for new medications or significant changes.)

Monitoring: [labs, vitals, rating scales to obtain] (Specify timing and responsibility.)

Psychotherapy/Psychosocial: [therapy status; school interventions; behavioral plans; caregiver guidance] (Include if relevant.)

Follow-up: [next appointment timing] — [contingency plan for worsening or safety concerns]