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medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.   Informed Consent Ability

Plan   (Note some items may only be applicable in the inpatient environment)

Pharmacologic Interventions Maintain the sertraline of 100 mg orally daily; increase to 150 mg to the next visit in case symptoms are not sufficiently controlled. Hydroxyzine should be continued if there are acute symptoms of anxiety. Strengthen medication compliance and check side effects.     Non-Pharmacologic Interventions Referral to Cognitive Behavioral Therapy (CBT). Education on sleep hygiene, walking daily, breathing relaxation and journaling. Strategies of managing weight and improving nutrition discussed.   Safety Assessment The patient rejects suicidal/homicidal ideation and is rated to have a low acute risk.   Follow-Up Follow-up in four weeks to review medication or earlier in case of the aggravation of the symptoms.     Billing Codes 99214, 90833 Provider: __________ Date/Time: _______________

Step-by-Step Guide for Writing a Complete Care Plan

Clinical Note Components – Sample Framework

Patient Diagnosis and ICD-10 Codes

• Primary Diagnosis: Generalized Anxiety Disorder (GAD) – ICD-10: F41.1

• Secondary/Associated Diagnosis (if applicable): Insomnia – ICD-10: F51.01

Patient Input Regarding Treatment Options

• Discussed treatment plan options with the patient, including:

  • Pharmacologic therapy with sertraline and hydroxyzine

  • Non-pharmacologic strategies such as Cognitive Behavioral Therapy (CBT), exercise, sleep hygiene, relaxation techniques, and nutrition management

• Patient expressed willingness to engage in therapy and lifestyle interventions, but noted obstacles: limited time for therapy sessions and challenges maintaining regular exercise due to work schedule.

Informed Consent Ability

• Patient demonstrated the ability to understand treatment options, associated risks/benefits, and provided informed consent for pharmacologic and non-pharmacologic interventions.

Plan

Pharmacologic Interventions

1. Continue sertraline 100 mg orally daily; increase to 150 mg at the next visit if symptoms remain uncontrolled.

2. Continue hydroxyzine for acute anxiety episodes as needed.

3. Emphasize medication compliance and monitor for side effects.

Non-Pharmacologic Interventions

1. Referral to Cognitive Behavioral Therapy (CBT).

2. Education on:

   • Sleep hygiene

   • Daily walking/exercise

   • Breathing relaxation techniques

   • Journaling for stress management

3. Discussed nutrition and weight management strategies.

Safety Assessment

• Patient reports no suicidal or homicidal ideation.

• Acute risk level assessed as low.

Follow-Up

• Follow-up scheduled in four weeks to review medication effectiveness.

• Earlier follow-up advised if symptoms worsen.

Billing Codes

• 99214: Office visit, established patient, moderate complexity

• 90833: Psychotherapy, 30 minutes with medication management

Provider: ______________________
Date/Time: ______________________

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1. Identify Diagnoses and ICD-10 Codes

   • Ensure both primary and secondary conditions are included.

   • Confirm accuracy using ICD-10 resources: CDC ICD-10 Codes.

2. Incorporate Patient Input

   • Include preferences, concerns, and obstacles to treatment.

   • Document any shared decision-making.

3. Determine Informed Consent Ability

   • Assess patient’s comprehension of treatment options and capacity to consent.

4. Create a Structured Plan

   • Separate pharmacologic and non-pharmacologic interventions.

   • Include dosage, frequency, and follow-up adjustments.

5. Include Safety Assessment

   • Document suicidal/homicidal ideation and risk level.

6. Specify Follow-Up

   • Indicate timeframes for monitoring and adjustments.

7. Billing and Documentation

   • Include accurate billing codes for medical and psychotherapy services.

   • Sign and date the documentation.

8. Review and Edit

   • Ensure grammar, spelling, and APA or EMR documentation standards are correct.

   • Confirm clinical reasoning and patient-centered planning are clear.

 

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