Psychological Assessment &

Treatment Plan

Assessment Date: _______ / _______ / _______ Name of Facility: ____________________________________________________

Patient Identifying Information

Patient Name: ___________________________________________________________________________________________

(Last) (First) (MI)

Patient Date of Birth: _______ / _______ / _______ Age: __________ Gender: ☐ Male ☐ Female
Marital Status: Ethnicity: Primary Language:
☐Single ☐Married ☐Caucasian ☐Native American ☐Black/African American ☐English
☐ Widowed ☐Divorced ☐Hispanic ☐Asian ☐Other: ______________ ☐Other: ______________

Reason For Referral:

* Measure 128
If BMI ≤ 22 or ≥ 30: Reason if no BMI or intervention plan:
Body Mass Index #: ☐ referred to diet / behavior professional OR ☐ Patient refused Measure not appropriate:
_______________ ☐ intervention plan already in place measure ☐ Pt on hospice ☐ Pt is pregnant
BMI = mass(lb) / (height(in))² x 703

Mental Health History:

Psychotropic Medication List:

Review

Medical Diagnosis:
Chart

Other Medications:

Neurological Damage or Dysfunction: If Yes, date: _______ / _______ / _______

☐ Yes ☐ No ☐ Cannot Determine Note:

(B) Hearing, Speech and Vision:

Minimum Data Set (MDS)

(C) Cognitive Patterns:

(D) Mood:

(E) Behavior:

(G) Activities of Daily Living:

(F) Preferences for Customary Routine and Activities:

(J) Pain: ☐ Yes ☐ No ☐ Cannot Determine

* Physician Quality Reporting System (PQRS) Psychological Assessment & Treatment Plan October 2015
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 Psychological Assessment & Patient Name: ____________________________
Treatment Plan

MENTAL STATUS EXAMINATION

APPEARANCE RESPONSIVENESS THOUGHT CONTENT (Preoccupations) THOUGHT CONTENT (Delusions)
neat eccentric alert lethargic none somatic symptoms none religious
unkempt seductive vigilant other: obsessions compulsions persecution grandiosity
meticulous bizarre anxious/fearful phobias suicide control jealousy
disheveled unusual physical SPEECH SPEECH violent acts guilt somatic bizarre
traits IMPAIRMENT QUANTITY sex worthlessness influenced by thought
FACIAL EXPRESSION none normal, THOUGHT PROCESSES others broadcasting
normal & responsive stuttering appropriate logical & tangential UNUSUAL PERCEPTUAL EXPERIENCES
sad, depressed worried echolalic talkative coherent evasive none Hallucinations:
expressionless neutral articulation unspontaneous perseveration blocking auditory visual
anxious/fearful bizarre, problem minimally circumstantial incoherent gustatory tactile
angry/hostile inappropriate responsive loose neologisms olfactory
AFFECT SPEECH QUALITY associations clang associations HALLUCINATORY EXPERIENCES
appropriate labile normal monotonous flight of ideas other: none incorporated into
blunted dramatized slow soft distracted fragmented, not delusions
restricted contradictory rapid loud ORIENTATION incorporated into
MOOD pressured slurred fully Disoriented person delusions
calm anxious hesitant mumbled oriented to: place MOTOR BEHAVOR
cheerful depressed emotional other: time normal ataxia
fearful tearful ATTITUDE / BEHAVIORAL TONE date/day tic slow, retarded
neutral pessimistic cooperative manipulative MEMORY INTELLECTUAL physical agitation movement
optimistic elated irritable immature good (intact) FUNCTION restlessness unusual &
euphoric irritable seductive uncooperative Estimated IQ: tremor of upper/ inappropriate
angry other: distractible demanding Impaired: above average lower extremity movement
INSIGHT JUDGEMENT apathetic withdrawn immediate recall average paralysis
good good aggressive other: recent memory below average ATTENTION & CONCENTRATION
fair fair overly remote memory within normal limits
poor poor dramatic short attention span
extremely unable to make LANGUAGE SKILLS difficulty sustaining concentration
limited reasonable language skills intact Signs of expressive global
decisions word-finding difficulty aphasia: receptive

* Measure 131
Pain Scale: Check applicable box:
☐ Patient reports no pain
☐ Patient referred for pain
management
OR
☐ Current plan still in effect
Clinical Interview

* Physician Quality Reporting System (PQRS)

Psychological Assessment & Treatment Plan October 2015
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 Psychological Assessment & Patient Name: ____________________________
Treatment Plan

* Measure 134
Depression Screening
Administer one of the following depression screening instruments: GDS (15 questions), GDS Short (5 questions), Cornell Depression Scale
Administered: Minutes to Admin Score: If no depression screen administered, provide reason:
☐ Yes ☐ No Geriatric Depression Scale - 15 questions
☐ Yes ☐ No Geriatric Depression Scale - 5 questions
(information reported below)

☐ Yes ☐ No Cornell Depression Scale

Geriatric Depression Scale – Short (5 questions)

1. Are you basically satisfied with life? Y N
2. Do you often get bored? Y N
3. Do you feel helpless? Y N
4. Do you prefer to stay home rather than going out and doing new things? Y N
5. Do you feel pretty worthless the way you are now? Y N
Geriatric Depression Scale Score: Answers in center column indicate depression. Although differing Total of center column answers:
sensitivities and specificities have been obtained across studies, for clinical purposes a score >2 points is
suggestive of depression and should warrant a follow-up interview (Reference: Frank Jacobson, Ph.D.)
* Measure 107
☐ Risk is not evident ☐ Ideation evident ☐ Intent evident
Suicide &
☐ Means evident ☐ Plan evident ☐ Plan – contract or watch to protect self/others, or
Homicide Risk
inform facility staff
Status
Formal Mental Status Screening
Administer the following mental status screening instrument: SLUMS
Administered: Minutes Score: If SLUMS not administered, provide reason:
to Admin
☐ Yes ☐ No St. Louis Mental Status Exam (SLUMS)
* Measure 181
☐ Negative screen for elder abuse or neglect
Elder Assessment Instrument
☐ Positive screen, follow up conducted
EAI administered to patients
☐ Screen not conducted – patient not eligible (i.e., age, patient refused to participate, patient is
≥ 65 years of age
in urgent situation where delayed treatment would jeopardize health)
Clinical Summary & Diagnostic Formulation:

* Physician Quality Reporting System (PQRS)

Psychological Assessment & Treatment Plan October 2015
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 Psychological Assessment & Patient Name: ____________________________
Treatment Plan

Diagnosis (ICD-10) Code and Full Description – (Provider must check the diagnosis which will be the focus of treatment)
TX DX Code Description

☐
Diagnosis

GAF:
* Measure 106
DX is Major DEP DO? If Yes, check: ☐ Initial Episode ☐ Recurrent Episode ☐ Unspecified
☐ Yes ☐ No If Yes, rate severity: ☐ Mild ☐ Moderate ☐ Severe
Additional PQRS Measures

* Measure 226
Does patient ☐ No, no action to take
currently use ☐ Yes, patient counseled (3 minutes) for cessation
tobacco? ☐ Not asked due to: short life expectancy, medically incapacitated, no opportunity to use tobacco
* Measure 247
Does the patient have a diagnosis of If Yes,
Alcohol Abuse or Dependence? ☐ The patient was counseled regarding psychosocial and pharmacologic options
☐ Yes ☐ No ☐ The patient was not counseled regarding psychosocial and pharmacologic options
* Measure 248
Does the patient have a diagnosis of If Yes,
Substance Abuse or Dependence? ☐ The patient was screened for depression
☐ Yes ☐ No ☐ The patient was not screened for depression for medical reasons
☐ The patient was not screened for depression
Initial Treatment Plan
☐ Patient consents to and is able to participate in and benefit from treatment
☐ Care coordinated with social services or nursing staff

The following Psychotherapy approaches will be implemented in treatment:

☐ Cognitive/Behavioral ☐ Cognitive/Behavioral Modified ☐ Insight-Oriented
☐ Person Centered ☐ Behavioral Modification ☐ Other:
Initial Treatment Plan

 The initial program of treatment is estimated at _______ months unless modified during the course of therapy. A review of
progress will be conducted within four (4) months or after 20 sessions if ongoing treatment is necessary.
 The patient will initially be seen _______ time(s) per week for _______ minute sessions.
Problem /
1 Symptom
Goal

Problem /
2 Symptom
Goal

___________________________________________________________________ _______ / _______ / _______

Signature of Licensed Psychologist Date of Completion
* Physician Quality Reporting System (PQRS)
Psychological Assessment & Treatment Plan October 2015
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