For my patients: Reminder list of important things to tell Dr. Fass for coding, documentation, assessment and treatment requirements at each visit (you can skip over items that don’t apply. NB: anything that you do NOT mention I will document as not applicable). For the remaining time we can discuss whatever you would like.
- Are there medication changes made by someone else or yourself?
- Are there medication changes you want me to make today and why?
- Do you need any refills of medication today?
- Have you had any lab tests done for your PCP or Dr. Fass? (If so, where and when)?
- What diagnosis and problems do you want to discuss?
- What if any changes have you noticed in your vital signs (weight, posture, Blood pressure, pulse rate and regularity, breathing rate and regularity)?
- What if any changes have you noticed in yourself (mood and affect, thought processes, hallucinations, judgment and insight, suicidal or homicidal ideas?
- Have your thoughts changed in any way? What have you been thinking about most?
- Have you done any reading relative to your condition(s): (handouts given, books recommended)?
- How have you changed your self-care (diet, exercise, social network, education, work and home environments)?
- Have you followed up on any of the recommendations for referrals? When are your next appointments with the person(s), or if not, why not?
- What are you hoping to work on next?