TTUHSC



|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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