What should be included in a psychiatric History of Present Illness (HPI) for a medication management follow-up visit?

Essential Components of a Psychiatric HPI for Medication Management Follow-Up Visits

A comprehensive psychiatric HPI for a medication management follow-up visit should focus on current symptom status, medication effects, side effects, adherence, and any new developments since the last visit to ensure optimal patient outcomes.

Core Components

Current Symptom Assessment

• Evaluate target symptoms that were the focus of initial medication management, including any changes in severity, frequency, or impact on functioning 1
• Assess for psychiatric review of systems, including anxiety symptoms, panic attacks, sleep disturbances, and impulsivity 1
• Document any new psychiatric symptoms that have emerged since the previous visit 1
• Use standardized rating scales when appropriate to track symptom changes objectively 1

Medication Assessment

• Review current medication adherence patterns, including missed doses and reasons for non-adherence 1
• Document response to current medications, including degree of symptom improvement 1
• Assess for medication side effects, particularly those common to psychiatric medications (e.g., sleep disturbances, appetite changes, weight fluctuations, sexual dysfunction) 1
• Evaluate for any new drug-drug interactions with changes in medication regimen 1

Functional Status

• Assess changes in social, occupational, and educational functioning since the last visit 1, 2
• Document impact of current symptoms and medication effects on quality of life 1
• Evaluate self-care abilities and need for additional support services 1

Risk Assessment

• Screen for current suicidal or homicidal ideation, plans, or intent 1
• Assess for any aggressive behaviors or thoughts since the last visit 1
• Document any self-injurious behaviors without suicidal intent 1

Substance Use Update

• Review current use of tobacco, alcohol, and other substances 1
• Document any changes in substance use patterns since the previous visit 1
• Assess for misuse of prescribed or over-the-counter medications 1

Additional Important Elements

Medical Update

• Note any new medical diagnoses, hospitalizations, or procedures since the last visit 1
• Document changes to non-psychiatric medications 1
• Assess for any new physical symptoms that could be related to psychiatric medications 1

Psychosocial Context

• Identify any new psychosocial stressors that may be affecting symptom presentation 1
• Document changes in social support, housing, or financial circumstances 1
• Assess for any traumatic experiences since the last visit 1

Treatment Planning Elements

• Document patient's perspective on medication benefits and drawbacks 1
• Assess patient's understanding of their treatment plan 1
• Note any barriers to treatment adherence 1

Common Pitfalls to Avoid

• Failing to assess medication adherence properly: Many patients do not take medications as prescribed but may not volunteer this information unless specifically asked 1
• Overlooking physical side effects: Systematic assessment of common side effects is essential, as patients may not associate physical symptoms with psychiatric medications 1
• Neglecting to document baseline vital signs: For medications that can affect cardiovascular function, documenting vital signs at each follow-up visit is crucial 3
• Missing drug-drug interactions: Always review the complete medication list, including over-the-counter medications and supplements 1
• Inadequate follow-up after hospitalization: Ensure proper documentation of post-hospital discharge follow-up, especially within the critical 7-day window after discharge 1, 4

Documentation Format

For efficient documentation, structure the medication management follow-up HPI in this sequence:

1. Chief complaint/reason for follow-up
2. Current psychiatric symptoms (target symptoms and others)
3. Medication adherence, response, and side effects
4. Functional status changes
5. Risk assessment
6. Substance use update
7. Medical/psychosocial updates
8. Patient's perspective on treatment 1

This structured approach ensures comprehensive assessment while maintaining focus on the primary purpose of medication management follow-up visits.