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Below is the reformatted clinical note using the standardized template:

=============================================================== Patient Information

• Name: Addison Marx
• Gender: Female
• Provider: Amanda Lantow (Specialty Code: 394800008)
• Date of Service: 10/07/2025
• Place of Service: 02 – Telehealth
• Visit Type: Established Patient

Chief Complaint

Medication follow-up for ADHD and anxiety management.

History of Present Illness (HPI)

The patient is an established female patient presenting via telehealth for psychiatric medication follow-up. She reports an overall improvement since her last visit with reduced anxiety and improved control of her thoughts. Key points include:

• Medication Effects:
– Currently taking immediate-release Adderall 10mg twice daily (morning and afternoon).
– Reports that dose increases yield good effect for approximately one week before waning.
– Denies difficulty with focus but notes feeling “a little sleepy still.”

• New Symptom:
– Increased itchiness and subsequent scalp picking leading to small red marks. This behavior is new since starting Adderall and the patient is working to stop it.

• Functional Impairment & School Performance:
– Reports doing well in school; a month off medication was described as “rough,” suggesting that the current regimen is effective.
– Example provided: Able to clean out the bathroom closet in about an hour without burnout, which is a marked improvement from prior experiences.

• Sleep:
– Working to correct sleep schedule.
– Notes that although she gets to bed at a better time now, it takes longer to fall asleep due to the new schedule and her historical poor sleep profile.

• Memory:
– Reports that memory is “getting better” and anticipates further improvement with consistent medication use and studying.

• History of Restless Legs:
– Long-standing history since postpartum trauma (“trauma postpartum when I was paralyzed”).
– Managed by taking evening doses shortly before bedtime; occasional difficulty returning to sleep if awakened.

Past Medical History (PMH)

• Not documented in the provided note.

Review of Systems (ROS)

• Neuropsychiatric:
– ADHD, anxiety symptoms, and new scalp itching/skin picking.
– Memory noted to be improving.
• Sleep:
– Sleep disturbances; difficulty with sleep onset despite earlier bedtimes.
• Neurological:
– History of restless legs since postpartum trauma.
• No additional systems explicitly documented.

Physical Examination

• Encounter: Telehealth visit
• Mental Status Examination (MSE):
– Appearance: Not fully assessable via telehealth
– Behavior: Cooperative and engaged
– Speech: Normal rate and rhythm (with a noted comment about speaking “around” her tongue)
– Mood: Reported as “good”
– Affect: Appropriate
– Thought Process: Logical, organized, and goal-directed
– Thought Content: No suicidal or homicidal ideation
– Cognition: Alert and oriented; coherent history provided
– Insight/Judgment: Good awareness regarding medication effects and side effects
• Vital signs: Not documented

Assessment / Diagnosis

1. Attention-Deficit/Hyperactivity Disorder (ADHD)
   – Managed with immediate-release Adderall 10mg twice daily.
   – Patient reports good focus and task completion despite a mild waning effect after dose increases.

2. Anxiety
   – Currently well-managed with improved control of thoughts noted by the patient.

3. New-onset Skin Picking Behavior
   – Likely related to increased itchiness since starting Adderall, resulting in scalp picking and small red marks.
   – Patient is actively working to discontinue this behavior.

4. Sleep Disturbance
   – Patient is making an effort to correct her sleep schedule, although some residual sleepiness remains.

5. History of Restless Legs
   – Long-standing condition since postpartum trauma; managed by appropriate timing of medication.

6. OCD Assessment
   – Subclinical with a total score of 4/40. No significant obsessive or compulsive symptoms requiring intervention.

Plan / Treatment

1. Adderall immediate-release 10mg
   – Continue current twice-daily regimen (morning and afternoon).
   – Prescription refill sent to the pharmacy for availability on the 16th.

2. Extended-release Adderall Prior Authorization
   – Continue efforts to obtain approval.
   – Patient to bring insurance paperwork to the office for provider completion.

3. Fluoxetine
   – Continue current dose (exact dose not specified; refills available per patient report).

4. Monitoring
   – Monitor for continued scalp itching and skin picking behavior.
   – Monitor ADHD symptoms and focus.
   – Monitor anxiety levels and obsessive-compulsive tendencies (currently subclinical).
   – Monitor sleep pattern and any further sleep disturbances.

5. Transition of Care
   – Patient expressed interest in transferring ADHD/anxiety medication management to her PCP for cost-effectiveness reasons.
   – Provider to see the patient one more time to ensure stability before transitioning; no additional monitoring requirements identified.

6. Follow-up
   – Next appointment scheduled for November 4, 2025, at 2:30 PM via telehealth.

7. Patient Education
   – Advised that controlled substance visits (Adderall) typically require follow-up every three months.
   – Encouraged patient to contact the office if concerns arise prior to the scheduled appointment.

Additional Documentation

• Informed Consent:
– Patient participated knowingly in a telehealth visit.
• Risk Assessment:
– No acute crisis or suicidal/homicidal ideation noted; stable psychiatric status.
• Signature/Date:
– Documentation finalized on 10/07/2025 as part of the telehealth session.

=============================================================== Quality Grade: High

Questions for Improvement: • Would additional details regarding the patient’s past medical history (beyond the current psychiatric concerns) enhance the overall understanding and continuity of care?
• Are there any other specific details about medication dosing or side effect management that should be documented further for future reference?

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