Document the skilled interventions delivered this visit; each should connect to a finding and carry a reassessment in Section 10.
Validated mood and anxiety screening with interpretation against the baseline.
Risk screening and, when positive, an immediate safety response — ensuring the patient is not left alone when acute risk is present, contacting the provider and emergency or crisis services per severity, mobilizing the 988 Suicide and Crisis Lifeline, and collaborating on a safety plan that includes reducing access to lethal means per agency protocol.
Assessment of psychiatric-medication adherence, effect, and side effects, and supportive, therapeutic communication.
Coordination of a mental-health referral and connection to services, and substance-use resource coordination where indicated.
Distinguishing a primary psychiatric presentation from a medical or delirium cause and coordinating medical evaluation when an acute change is present.
