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|TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER |REVIEW NO: |NUMBER: |
|SCHOOL OF MEDICNE | | |
|PSYCHIATRY DEPARTMENT |2 | |
|POLICY AND PROCEDURE | |MR 5 |
|PREPARED BY: APPROVED BY: |ORIGINAL |MOST RECENT REVIEW |
| |APPROVAL DATE: |APPROVAL DATE: |
|Kary Blair Terry McMahon, M.D. |APRIL 1993 |December 4, 2018 |
|TITLE: |PAGE: |
|Documentation of Allergies | |
| |1of 1 |
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|A. GENERAL STATEMENT OF POLICY |
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|Statement of Purpose: To document and update all patient allergies appropriately. |
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|B. SCOPE: |
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|This policy covers Psychiatry |
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|C. AMINISTRATION & PROCEDURE: |
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|a. Drug allergies will be documented in the patient EMR chart as follows: |
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|1. On Psychiatry Initial Evaluation |
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|b. Nursing personnel and clinician will be responsible for documenting allergies and reviewing and updating at every clinic visit. |
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|D. DISTRIBUTION : |
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|This policy shall be distributed to Psychiatry |
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| | |
|TTUHSC School of Medicine, Department of Psychiatry |Name |
|and Behavioral Sciences Lubbock, Texas Page 1 of 2 |Date |
|PSYCHIATRIC DIAGNOSIS |TTUHSC MRN |
▪ Psychiatric Diagnosis :
DMS-IV CODE:
AXIS I
AXIS II
AXIS III
| |
|ALLERGIES: |
AXIS IV Primary Support Group Economic
Social Environment Access to Health Care
Educational Problems Legal System
Occupational None Identified
Housing Other
AXIS V Current GAF Past Year GAF
Physician/PA Signature Date
Psychiatric Diagnosis 9/05 LMM *Diagnosis must be updated whenever diagnosis changes
|COMMON DSM-IV DIAGNOSIS CODES |
|DISORDER FROM INFANCY, |MOOD DISODERS |EATING DISORDERS |
|CHILDHOOD, ADOLESCENCE |MDD & Bipolar I, 5th digit: 1=mild, |307.1 Anorexia Nervosa (Specify type) |
|317 Mild Mental Retardation (on Axis II) |2=moderate, 3=severe w/o psychotic feature, |307.51 Bulimia Nervosa (Specify type) |
|318.0 Moderate MR (on Axis II) |4=severe w/psychotic features |307.50 Eating Disorder NOS |
|318.1 Severe Mental Retardation (on Axis II) |296.2x MDD, Single Episode | |
|318.2 Profound MR (on Axis II) |296.3x MDD, Recurrent |DISSOCIATIVE DISORDERS |
|319 MR, Severity Unspecified (on Axis II) |300.4 Dysthymic Disorder |300.14 Dissociative Identity Disorder |
|315.00 Reading Disorder |311 Depressive Disorder NOS |300.15 Dissociative Disorder NOS |
|315.1 Mathematics Disorder |296.xx Bipolar I Disorder | |
|315.2 Disorder of Written Expression |.0x Single Manic Episode (Specify if Mixed) |ADJUSTMENT DISORDERS |
|315.9 Learning Disorder NOS |.40 MRE Hypomanic |309.xx Adjustment Disorder (acute of chronic) |
|307.0 Stuttering |.4x MRE Manic |.0 With Depressed Mood |
|307.9 Communication Disorder NOS |.5x MRE Depressed |.24 With Anxiety |
|315.31 Expressive Language Disorder |.6x MRE Mixed |.28 W/ Mixed Anxiety & Depressed Mood |
|315.32 Mixed Recept-Express Language D/O |.7 MRE Unspecified |.3 With Disturbances of Conduct |
|315.39 Phonological Disorder |296.89 Bipolar II Disorder (Specify MRE) |.4 W/Mixed Disturb of Emot & Conduct |
|312.9 Disruptive Behavior Disorder |301.13 Cyclothymic Disorder |.9 Unspecified |
|314.9 ADHD NOS |296.80 Bipolar Disorder NOS | |
|314.00 ADHD Inattentive Type |293.83 Mood Disorder Due to (Specify GMC) |PERSONALITY DISORDERS |
|314.01 ADHD Hyperactive-Impulsive Type |(Specify: with major depressive-like-episode or |301.0 Paranoid Personality D/O (on axis II) |
|314.01 ADHD Combined Type |depressive, manic, or mixed features) |301.20 Schizoid Personality D/O (on axis II) |
|313.81 Oppositional Defiant Disorder |296.90 Mood Disorder NOS |301.22 Schizotypal Personality D/O (on axis II) |
|312.81 Conduct Disorder, Childhood Onset | |301.7 Antisocial Personality D/O (on axis II) |
|312.81 Conduct Disorder, Adolescent Onset |ANXIETY DISORDERS |301.83 Borderline Personality D/O (on axis II) |
|312.81 Conduct Disorder, Unspecified Onset |300.01 Panic Disorder w/o Agoraphobia |301.50 Histrionic Personality D/O (on axis II) |
|307.23 Tourette’s Disorder |300.21 Panic Disorder with Agoraphobia |301.81 Narcissistic Personality D/O (on axis II) |
|307.20 Tic Disorder NOS |300.22 Agoraphobia w/o hx of Panic D/O |301.82 Avoidant Personality D/O (on axis II) |
|309.21 Separation Anxiety Disorder |300.29 Specific Phobia (Specify Type) |301.6 Dependent-Personality D/O (on axis II) |
|299.80 Pervasive Development D/O NOS |300.23 Social Phobia |301.4 Obsessive-Compulsive D/O (on axis II) |
|299.80 Asperger’s Disorder |300.3 Obsessive-Compulsive Disorder |301.9 Personality Disorder NOS (on axis II) |
|299.00 Autistic Disorder |309.81 PTSD (acute, chronic, or w/delayed onset) | |
|307.6 Enuresis (Not Due to GMC) |308.3 Acute Stress Disorder |MEDICATION-INDUCED SX’s |
| |300.02 Generalized Anxiety Disorder |332.1 Neuroleptic-Induced Parkinsonism |
|SUBSTANCE USE DISORDERS |293.84 Anxiety D/O Due to (Specify GMC) |333.92 NMS |
|303.90 Alcohol Dependence |300.00 Anxiety Disorder NOS |333.7 Neuroleptic-Induced Acute Dystonia |
|305.00 Alcohol Abuse | |333.99 Neuroleptic-Induced Acute Akathisia |
|291.89 Alcohol-Induced Mood Disorder |COGNITIVE DISORDERS |333.82 Neuroleptic-Induced T.D. |
|304.40 Amphetamine Dependence |Dementia, 5th digit: 0=W/O Behavioral |333.1 Medication-Induced Postural Tremor |
|305.70 Amphetamine Abuse |Disturbance, 1=W/Behavioral Disturbance |333.90 Med-Induced Movement Disorder NOS |
|292.89 Amphetamine-Induced Sleep Disorder |294.1x Dementia of the Alzheimer’s type |995.2 Adverse Effects of Medication NOS |
|305.90 Caffeine Intoxication |(Specify: Early vs Late Onset) | |
|292.89 Caffeine-Induced Anxiety Disorder |294.1x Dementia 2O to (Specify GMC) |COMMON V CODES |
|292.89 Caffeine-Induced Sleep Disorder |290.40 Vascular Dementia, Uncomplicated |V61.9 Relational Problem Related to Mental |
|292.89 Caffeine-Related Disorder NOS |290.41 Vascular Dementia, with Delirium |Disorder or GMC |
|304.30 Cannabis Dependence |290.42 Vascular Dementia, with Delusions |V61.20 Parent-Child Relation Problem |
|292.9 Cannabis-Related Disorder NOS |290.43 Vascular Dementia, w/Dep. Mood |V61.10 Partner Relational Problem |
|304.20 Cocaine Dependence |294.8 Dementia NOS |V61.8 Sibling Relational Problem |
|305.60 Cocaine Abuse |294.9 Cognitive Disorder NOS |V62.81 Relational Problem NOS |
|292.89 Cocaine-Induced Sleep Disorder | |V15.81 Noncompliance with Treatment |
|304.50 Hallucinogen Dependence |SCHIZOPHRENIA/PSYCHOSES |V62.89 Borderline Intellectual Funct (Axis II) |
|305.30 Hallucinogen Abuse |295.30 Paranoid Schizophrenia |V62.82 Bereavement |
|304.60 Inhalant Dependence |295.10 Disorganized Schizophrenia |V61.21 Physical Abuse of Child |
|305.90 Inhalant Abuse |295.20 Catatonic Schizophrenia |(995.54 if focus is on victim) |
|292.82 Inhalant-Induced Persisting Dementia |295.90 Undifferentiated Schizophrenia |V61.21 Sexual Abuse of Child |
|305.1 Nicotine Dependence |295.60 Residual Schizophrenia |(995.53 if focus is on victim) |
|304.00 Opioid Dependence |295.40 Schizophrenia Disorder |V61.21 Neglect of Child |
|305.50 Opioid Abuse |(Specify: Bipolar or Depressive Type) |(995.52 if focus is on victim) |
|304.60 PCP Dependence |297.1 Delusional Disorder (Specify Type) |V61.12 Physical Abuse of Adult (by Partner) |
|305.90 PCP Abuse |298.8 Brief Psychotic Disorder |V62.83 Physical Abuse of Adult (by Other) |
|304.10 Sedative, Hypnotic, Anxiolytic Dep. |293.xx Psychotic D/O 2O to (Specify GMC) |(995.81 if focus is on victim) |
|305.40 Sedative, Hypnotic, Anxiolytic Abuse |.81 With Delusions |V61.12 Sexual Abuse of Adult (by Partner) |
|304.80 Polysubstance Dependence(>3) |.82 With Hallucinations |V62.83 Sexual Abuse to Adult (by Other) |
|304.90 Other/Unknown Substance Depend. |298.9 Psychotic Disorder NOS |(995.83 is focus is on victim) |
|305.90 Other/Unknown Substance Abuse | |V71.09 No Diagnosis on Axis I or II |
| | |799.9 Diagnosis Deferred on Axis I or II |
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