Name Of The Nurse Practitioner Month Of Supervision Name/Credentials Of The Psychiatrist (optional) Date Of The Supervision Duration Of The Supervision (optional) Topic Of Supervision QUALITY IMPROVEMENT MEETING CASE CONFERENCE PSYCHOPHARMACOLOGY LECTURE & TOPIC QUESTION/ANSWER SESSION OTHER PERCENTAGE OF CHARTS CO-SIGNED NUMBER OF PHONE/EMAIL CONTACTS (MONTH) CONTROLLED PRESCRIPTION SENT Patient Information Yes No Informed Consent Yes No History Taking & Clinical Interviewing Diagnosis or presenting problem Satisfactory Average Good Excellent in all below Differential diagnosis Satisfactory Average Good Excellent in all below Treatment Plan Satisfactory Average Good Excellent in all below Knowledge of Psychopharmacology Medication doses Satisfactory Average Good Excellent in all below Side effects Satisfactory Average Good Excellent in all below FDA indications Satisfactory Average Good Excellent in all below Drug interactions Satisfactory Average Good Excellent in all below Non-pharmacological interventions recommended Satisfactory Average Good Excellent in all below Any changes to the treatment plan discussed during supervision Satisfactory Average Good Excellent in all below Progress Notes Documentation of the patient's progress since the last session Satisfactory Average Good Excellent in all below Any significant changes or improvements noted Satisfactory Average Good Excellent in all below Adequate documentation of symptoms Satisfactory Average Good Excellent in all below Adequate documentation of symptoms Satisfactory Average Good Excellent in all below Side effects Satisfactory Average Good Excellent in all below Medication Management Any side effects or adverse events reported Satisfactory Average Good Excellent in all below Adjustments made to medication regimens Satisfactory Average Good Excellent in all below Therapeutic Interventions Satisfactory Average Good Excellent in all below Evidence-Based Practice Evidence-Based Practice Satisfactory Average Good Excellent in all below Safety and Risk Assessment Evaluation of the patient's risk of harm to self or others Satisfactory Average Good Excellent in all below Any safety plans or interventions put in place Satisfactory Average Good Excellent in all below Use of Psychotherapeutic Techniques Description of any therapy or counselling provided Satisfactory Average Good Excellent in all below Progress in therapy and any challenges discussed Satisfactory Average Good Excellent in all below Ethical Considerations & Patient Rights Awareness Ethical Considerations & Patient Rights Awareness Satisfactory Average Good Excellent in all below Communication and Collaboration Any consultations or referrals made to other healthcare providers Satisfactory Average Good Excellent in all below Interactions with the patient's primary care physician or other specialists Satisfactory Average Good Excellent in all below Diagnostic Abilities & Use of DSM-5 Diagnostic Abilities & Use of DSM-5 Satisfactory Average Good Excellent in all below Clinical Judgment & Decision Making Clinical Judgment & Decision Making Satisfactory Average Good Excellent in all below Follow-Up Plan Follow-Up Plan Yes No Submit