Print this page to PDF and hand it to whoever builds the template in Tebra.
Purpose: Recreate the structure of the WPDM™ Initial Evaluation provider checklist (HPI, Review of Systems, Mental Status Exam, and Risk domains) as a Tebra custom clinical note type with checkbox and +/− presence items.
This is the structure only. Tebra templates are static — they capture the provider's clicks but do not run the WPDM scoring or AI narrative generation. Document the encounter in Tebra using this template; if you still want the AI-generated note, generate it in the WPDM app and paste the finished narrative into the Assessment/Plan free-text.
Create the custom note type
Psychiatric Initial Evaluation (WPDM)Build a template per section
check fields)radio "Denies / Yes"; ROS status)rating / number)text / textarea)| Item | Tebra type | Options | |---|---|---| | Chief Complaint | Free text | (auto-fills from appointment reason) | | Presenting concern | Free text | — | | Duration of symptoms | Free text | — |
For each system: one +/− presence item; if positive, a checkbox sub-list.
| ROS System | Symptom checkboxes | |---|---| | Constitutional | Fatigue, Weakness, Fever, Chills, Night sweats, Weight loss, Weight gain | | HEENT | Headaches, Vision changes, Blurred vision, Hearing changes, Tinnitus, Sinus symptoms, Sore throat, Dental concerns | | Cardiovascular | Chest pain, Palpitations, Dizziness, Syncope/fainting, LE swelling, Hypertension history | | Respiratory | Shortness of breath, Cough, Wheezing, Asthma, Sleep apnea | | GI | Nausea, Vomiting, Diarrhea, Constipation, Abdominal pain, Heartburn/reflux, Appetite change | | GU / Reproductive | Urinary frequency/urgency, Dysuria, Incontinence, Libido change, Sexual dysfunction, Menstrual changes, Pregnancy, Postmenopausal | | Musculoskeletal | Joint pain, Muscle pain, Weakness, Back pain, Neck pain, Chronic pain, Arthritis | | Neurological | Headaches, Dizziness, Tremor, Numbness/tingling, Weakness, Balance problems, Seizure history, Memory concerns | | Endocrine | Heat/cold intolerance, Excessive thirst, Excessive urination, Thyroid disorder, Diabetes | | Skin / Integumentary | Rash, Hives, Itching, Dry skin, Hair loss, Skin lesions | | Hematologic / Immunologic | Easy bruising/bleeding, Anemia, Frequent infections, Autoimmune condition | | Allergic / Immunologic | Hives, Recurrent allergic symptoms, Environmental allergy, Immune/autoimmune concerns |
| Item | Tebra type | Options | |---|---|---| | Appearance | Checkbox | Well-groomed, Appropriate, Disheveled, Other | | Behavior | Checkbox | Cooperative, Calm, Guarded, Agitated, Withdrawn, Other | | Speech | Checkbox | Normal rate/rhythm, Pressured, Rapid, Slowed, Sparse, Other | | Affect | Checkbox | Congruent, Restricted, Blunted, Labile, Other | | Thought Process | Checkbox | Linear/goal-directed, Circumstantial, Tangential, Disorganized, Other | | Thought Content | Checkbox | Unremarkable, Preoccupied, Obsessional, Paranoid, Other | | Perception | Checkbox | No perceptual disturbance, Hallucinations reported, Other | | Cognition / Orientation | Checkbox | Alert, Oriented, Attention intact, Other | | Insight | Checkbox (single) | Good, Fair, Limited, Poor | | Judgment | Checkbox (single) | Good, Fair, Limited, Poor | | Mood (stated) | Short answer | (free text) | | Additional MSE observations | Free text | — |
Cognitive Testing (optional):
| Item | Tebra type | Options | |---|---|---| | Serial 7s (100→93→86→79→72→65) | +/− or checkbox | Correct, Incorrect, Unable, Not assessed | | WORLD backwards | +/− or checkbox | Correct, One error, Multiple errors, Unable, Not assessed | | Months in reverse | +/− or checkbox | Completed accurately, One error, Multiple errors, Unable, Not assessed | | Immediate recall (Apple/Penny/Table) | +/− or checkbox | Recalled, With cue, Not recalled | | Delayed recall (Apple/Penny/Table) | +/− or checkbox | Recalled, Category cue, Multiple-choice cue, Not recalled |
| Item | Tebra type | Options | |---|---|---| | Suicidal Ideation | Checkbox | Denies, Passive thoughts, Active thoughts, Plan present, Intent present, Unable to assess | | Homicidal Ideation | Checkbox | Denies, Thoughts present, Target identified, Plan present, Intent present, Unable to assess | | Auditory Hallucinations | Checkbox | Denies, Current, Past, Command hallucinations, Unable to assess | | Visual Hallucinations | Checkbox | Denies, Current, Past, Unable to assess | | Self-Injurious Behavior | Checkbox | Denies, Current, Past | | SIB — Type (if present) | Checkbox | Cutting, Burning, Scratching, Hitting self, Hair pulling, Skin picking | | SIB — Last occurrence | Free text | — | | Suicide Attempt History | Checkbox | Denies, Yes, Unclear, Not assessed | | # Attempts (if Yes) | Numeric | — | | Most recent — date/method | Free text | — | | Medical treatment required | +/− | No / Yes | | Psychiatric hospitalization | +/− | No / Yes | | Intent at time | Checkbox | Low, Moderate, High, Unknown | | Prior Psychiatric Hospitalizations | Checkbox | None, Yes, Unknown | | # Hospitalizations (if Yes) | Numeric | — | | Most recent — date/facility | Free text | — | | Reason | Checkbox | Suicidal ideation, Suicide attempt, Mania, Psychosis, Severe depression, Aggression, Substance-related | | Physical Abuse History | Checkbox | Denies, Yes, Suspected, Prefers not to discuss, Not assessed | | Physical abuse — timing | Checkbox | Childhood, Adolescence, Adulthood, Current relationship | | Physical abuse — perpetrator | Free text | — | | Physical abuse — current safety concern | +/− | No / Yes | | Sexual Abuse History | Checkbox | Denies, Yes, Suspected, Prefers not to discuss, Not assessed | | Sexual abuse — timing | Checkbox | Childhood, Adolescence, Adulthood | | Sexual abuse — current safety concern | +/− | No / Yes | | Living Environment | Checkbox | Stable, Supportive, Stressful, Unsafe, Unstable |
| Item | Tebra type | Options | |---|---|---| | Current psychiatric diagnoses | Checkbox | MDD, GAD, Panic Disorder, PTSD, Bipolar I, Bipolar II, Cyclothymia, ADHD, OCD, PMDD, Schizophrenia, Schizoaffective, ASD, IDD, SUD, Adjustment Disorder, Under evaluation | | Medical diagnoses | Free text | — | | Family psychiatric history | Checkbox | Depression, Anxiety, Bipolar, Schizophrenia/psychosis, ADHD, ASD, SUD, Suicide attempt, Suicide death, Psychiatric hospitalization, None known, Unknown | | Illicit / non-prescribed drug use | Checkbox | Denies, Current use, Past use, In remission, Not assessed | | Substances (if used) | Checkbox | Cannabis, Cocaine, Methamphetamine, Opioids, Hallucinogens, MDMA, Sedatives/benzos (non-Rx), Rx misuse | | Alcohol use | Checkbox | Denies, Current, Past, In remission, Not assessed | | Alcohol — frequency | Checkbox | Daily, Several times weekly, Weekly, Social/occasional, Rare | | Alcohol — typical amount | Free text | — | | Alcohol — binge drinking | +/− | No / Yes / Unknown | | Alcohol — history | Checkbox | Blackouts, Withdrawal, Detox, DUI, Alcohol-related hospitalization, Treatment program, None | | Sleep — avg hours/night | Numeric | — | | Sleep — quality | Checkbox | Good, Fair, Poor | | Sleep — concerns | Checkbox | Difficulty falling asleep, Frequent awakenings, Early-morning awakening, Hypersomnia, Nightmares, Restless sleep, Decreased need for sleep, Daytime sleeping, Sleep apnea, Uses CPAP | | Depression — rating | Numeric (0–10) | — | | Depression — symptoms | Checkbox | Depressed mood, Anhedonia, Low motivation, Low energy, Hopelessness, Worthlessness, Excessive guilt, Crying spells, Social withdrawal, Poor concentration, Psychomotor slowing, Irritability, Sleep disturbance, Appetite disturbance, Suicidal thoughts | | Anxiety — rating | Numeric (0–10) | — | | Anxiety — symptoms | Checkbox | Excessive worry, Racing thoughts, Restlessness, Muscle tension, Irritability, Poor concentration, Feeling on edge, Palpitations, Shortness of breath, Chest tightness, GI distress, Panic attacks, Avoidance | | Current stressors | Checkbox | Work, School, Financial, Relationship, Marriage, Divorce/separation, Family conflict, Parenting, Housing, Legal, Medical illness, Chronic pain, Grief/loss, Caregiving, Social isolation, Transportation, Pregnancy/postpartum, Medication concerns, Trauma reminders | | Education — highest level | Checkbox | Less than high school, HS diploma, GED, Some college, Associate, Bachelor's, Master's, Doctoral/professional, Trade/vocational, Currently enrolled | | Employment — status | Checkbox | Full-time, Part-time, Self-employed, Unemployed, Student, Retired, Disabled, Medical leave |