Thank you, I did only send a snippet just because of the length. I included the note. I really can use some help understanding if this note process is acceptable for medical necessity and compliance. My other concern with this process of using the codes as their diagnosis assessment, following the guidelines for such things as combo codes, excludes, add also, highest specificity, etc.
Presenting Problem:
Patient is a 30-year-old female present to open access for medication management and therapy. Patient reports she is in the process of relocating out of due to relapsing. Patient reports she often finds herself getting bored and wanting to feel something.
Current Symptoms:
Depression-the patient endorsed cannot sleep well, trouble falling asleep, loss of interest, memory problems, change in appetite, weight gain, mood changes, fatigue, and trouble in relationships. Patient reports she is experiencing changes in her environment which effects her sleep, she reports to losing employment and lost her car, she reports it will take her half an hour to fall asleep. The patient reports for the past couple of months she loss interest in socialization and painting, she reports to having "depressed sleep in March 2026". The patient reports to experiencing her short term memory is not well, especially in events of substance use, effecting ability to recall. Patient reports to eating too much and nothing at all sometimes, she reports a history of eating disorder. Patient reports she gained weight during sobriety periods and lost 10lbs during relapse periods. The patient reports she can have high highs, but her mood will shift slightly during the day. She reports feeling overall tired all the time, no energy, and lack of motivation. Patient reports difficulty in relationships with her family, as the will communicate disappointment in her substance use for the past ten years.
Anxiety-the patient endorsed worry, episodes of time you can't remember, panic, thoughts that bother you, behaviors that bother you, and difficulty being alone. She reports to worrying about remaining clean, finding employment, and family issues of them constantly being disappointed in her ability to maintain sobriety. Patient reports to having blackouts "slight", talking with friends and not being able to recall conversations, especially under the influence of substances. The patient reports to experiencing panic like symptoms depends on situations such as racing thoughts, sweating, heart racing, and anxiousness. She reports to feeling like she can't stay sober and make it, having a better support system is now making things better, and processing the upcoming court case with her ex. The patient disclosed feeling down on herself by using substances, picking up random men to find substances, and unsafe activities to ensure she can use substances. She reports there are moments when she is alone she gets into her head and feels discomfort which leads to substance use.
ADHD-the patient endorsed hard to concentrate and trouble making decisions. Patient reports lack of ADHD medications is challenging to complete tasks and stay on track, in addition to poor impulse skills.
Emotional abuse-she reports her family and friends communicate to her negatively and people stating they are better than her.
Problems at work, home, school-patient reports to being under the influence at work, effecting her ability to be on time.
Physical/Sexual-past sexual abuse from a neighbor during her childhood and physical abuse in personal relationships.
Mental Health (Current/Past):
Diagnosis-Patient reports a historical diagnosis of Bipolar, Depression, Anxiety, ADHD, and substance use five years ago. The patient reports while atshe was prescribed Vyvanse 70mg/once per day for ADHD,; last taken in April 2026, Abilify 20mg/once per day for Bipolar; last taken in April 2026, Clonidine .01mg/three times per day for anxiety; last taken May 7, 2026, Propanol 40mg/three times per week for anxiety,; last taken May 1, 2026, Seroquel 200mg/once per day for sleep; last taken May 7, 2026, Topiramate 50mg/once per day for cravings; last taken April 2026, Gabapentin 300mg/three times per day for anxiety; last taken May 7, 2026, and Propranolol 40mg/three times per day for anxiety. The patient reports she feels stable when she takes her medications consistently, however, wants to discuss readjusting dosages for anxiety.
Inpatient - Dual diagnosis at in November 2025-January 2026, June 2025-October 2025, and iin 2020.
Outpatient -Denies
SI/Self-harm -Patient reports to self-harming a few years; no current suicidal ideations, intent, or plan.
HI/AVH -Denies
Trauma -Patient reports she was sexually abused as a child and experienced physical abuse in her past relationships.
Suicide Screen/Risk Assessment Completed: Yes
Substance Use (Current/Past):
Current Use/Past-
Heroin-first use at age 18, last use in 2025. Patient reports to using daily 2 grams by inhalation. Patient reports a period of sobriety for eight months in 2024. Experienced withdrawals, one overdose and received two doses of Narcan.
Crack-first use at age 19, last use May 4, 2026. Patient reports to using daily 3.5 grams by smoking. Periods of sobriety from November 2025-March 2026, she reports to being in sober living during this time.
Alcohol-first use at age 15, last use May 7, 2026. Patient reports to drinking weekly, three shorts and worked at a bar for several years. She has an OWI from 2019.
Cocaine-first use at age 19, last use April 2026. Patient reports to inhalation one per day. She reports a period of sobriety for one month while
Meth-first use at age 21, last use April 2026. Patient reports to taking one hit after maintaining sobriety for one year, "just because it was there".
Marijuana-first use at 14, last use April 2026. Patient reports to smoking daily for a couple of weeks, a couple of puffs.
Tobacco-vaping nicotine daily, not interested in cessation resources.
Past Treatments-
She reports going into detox 4/5 times at Rogers.
Inpatient treatment from November 28, 2025-January 12, 2026 at , followed by outpatient treatment at from January 12, 2026-March 23, 2026.
Outpatient treatment from June 2025-October 2025
Inpatient and outpatient treatment May 2024.
IOP five times total, last time completed in 2024 followed by IOP
Periods of Sobriety -patient reports no significant periods of sobriety, she reports to relapsing while in outpatient treatments
Transportation - Uber, Walking
Medical Issues/Physical Conditions (Current/Past):
Medical Conditions - Seizure, vision problems
Medications - Wears glasses
Allergies - Amoxicillin
Prescriber Interest - Yes
Strengths/Supports: Support System, Community Support Groups, Expresses Motivation, Spiritual/Religious/Cultural Affiliation, Education/Training, Transportation
Other - Strengths/Supports:
Determined, Empathetic, Team Player, Hard Worker
Other Biopsychosocial Concerns Identified: Employment, Housing/Basic Needs
Client Perspective:
"to get some stability and treatment"
Clinical Impressions:
The patient presented with some insight and motivation to stabilize. The patient presented to open access for psychiatric medication management and individual therapy following discharge from WisHope due to relapse. She reports chronic struggles to maintain sobriety after completion of inpatient treatment and describes an extensive history of dual diagnosis treatment, including multiple inpatient admissions at Denoon, WisHope, and a facility in FL. She reports engaging in IOP and PHP levels of care beginning in 2024 with limited sustained sobriety and recurrent relapses following discharge from structured environments. The patient was participating in psychiatric medication management while at WisHope, including cravings management, however, has been non-compliant with medications since April 2026. The patient reported a historical diagnoses of Bipolar Disorder, Depression, Anxiety, and ADHD in which she received five years ago. She did endorse depressive, anxiety, and ADHD related symptoms including sleep disturbances, fatigue, mood instability, worry, intrusive thoughts, and emotional distress, which appear to be increased with substance use and withdrawal patterns. Trauma related symptoms appear significant and warrant further monitoring once sustained sobriety.
DX DATE DX CODE DX_RANKING DIAGNOSIS REMARKS STATUS
2026-05-08 F14.20 1 Cocaine use disorder, severe Active
2026-05-08 F10.20 2 Alcohol use disorder, severe Active
2026-05-08 F15.20 3 Methamphetamine use disorder, severe Active
2026-05-08 F12.20 4 Cannabis use disorder, severe Active
2026-05-08 F11.21 5 Heroin use disorder, severe, in sustained remission Active
2026-05-08 F32.A 6 Depression, unspecified Active
2026-05-08 F41.9 7 Unspecified anxiety disorder Active
Diagnosis Entered: Yes
Recommendations and Initial Treatment Plan:
The patient met ASAM 2.1 level of care, intensive outpatient services and is referred to co-occurring IOP with The patient is also recommended to medication management with . The patient presents with lack of coping skills, chronic relapse history, unresolved trauma, and emotional dysregulation, and ongoing substance use. Patient is willing to engage in treatment, she can benefit from insight into relapse patterns, and motivation to stabilize mental health and substance use symptoms. The patient is referred to seeking strength group and is willing to accept the recommendation.
Collateral information was obtained at time of assessment from patient's CAAP. There will be ongoing attempts to obtain this information in future sessions to aid with ongoing assessment of treatment needs. Interim services will be determined based on need.
Status: Final