Lemonaid DA Visits
[comment memo="Cannot Treat"] [checkbox name="xtreat" value=""][conditional field="xtreat" condition="(xtreat).is('')"] PHONE - Identity confirmed. Competent. Medical history reviewed. Sounded alert and oriented. No apparent distress. Reviewed with patient my name and licensure in state.Reviewed medical history and spoke with patient. Upon review, it is noted that [checkbox name="moodstabilizers" value="pt with history of bipolar disorder|patient with history of mood stabilizers/atypical psych medications listed in DS|hx of controlled substance use in DS|sig family hx bipolar disorder"]. [checkbox name="quest2" value="MDQ performed and is found to be positive|Pt verifies known hx bipolar disorder|Patient does state that they are requesting refill of controlled substance"]. Protocols explained to patient. They are told that we cannot currently treat. Patient verbalizes understanding of this. Refund procedure explained. Answered all questions. Recommended in person care. Will not treat. Secure message sent to reinforce education provided.[/conditional] [comment memo="A/P"] [checkbox name="ap" value=""][conditional field="ap" condition="(ap).is('')"] PHONE - Identity confirmed. Competent. Medical history reviewed. Appeared alert and oriented. No apparent distress. Reviewed with patient my name and licensure in state. A/P: [checkbox name="Dx" value="Depression|Anxiety|Insomnia"] [select name="sig" value=" |Start|Continue|Stop|Increase|Decrease"] [select name="med" value="|**SSRI**|fluoxetine 10 mg PO qd|fluoxetine 20 mg PO qd|fluoxetine 40 mg PO qd|fluoxetine 60 mg PO qd|---|escitalopram 5 mg PO qd|escitalopram 10 mg PO qd|escitalopram 20 mg PO qd|---|sertraline 25 mg PO qd|sertraline 50 mg PO qd|sertraline 100 mg PO qd|sertraline 150 mg PO qd|---|citalopram 10 mg PO qd|citalopram 20 mg PO qd|citalopram 40 mg PO qd|---|paroxetine 10 mg PO qd|paroxetine 20 mg PO qd|paroxetine 40 mg PO qd||**ANX/INS**|hydroxyzine 25 mg QID PRN|hydroxyzine 25-50 mg PO qHS PRN|Trazodone 50 mg PO qHS PRN|Trazodone 100 mg PO qHS PRN||**SNRI**|bupropion 150 mg XL po qd|bupropion 300 mg XL PO qd|bupripion 450 mg PO qd|---|venlafaxine XR 37.5 mg PO qd|venlafaxine XR 75 mg PO qd|venlafaxine XR 150 mg PO qd|venlafaxine XR 37.5 mg PO qd|venlafaxine XR 225 mg PO qd"] [checkbox name="titration" value="with rapid titration over 1 month"] [select name="sig2" value=" |Start|Continue|Stop|Increase|Decrease"] [select name="med2" value="|**SSRI**|fluoxetine 10 mg PO qd|fluoxetine 20 mg PO qd|fluoxetine 40 mg PO qd|fluoxetine 60 mg PO qd|---|escitalopram 5 mg PO qd|escitalopram 10 mg PO qd|escitalopram 20 mg PO qd|---|sertraline 25 mg PO qd|sertraline 50 mg PO qd|sertraline 100 mg PO qd|sertraline 150 mg PO qd|---|citalopram 10 mg PO qd|citalopram 20 mg PO qd|citalopram 40 mg PO qd|---|paroxetine 10 mg PO qd|paroxetine 20 mg PO qd|paroxetine 40 mg PO qd||**ANX/INS**|hydroxyzine 25 mg QID PRN|hydroxyzine 25-50 mg PO qHS PRN|Trazodone 50 mg PO qHS PRN|Trazodone 100 mg PO qHS PRN||**SNRI**|bupropion 150 mg XL po qd|bupropion 300 mg XL PO qd|bupripion 450 mg PO qd|---|venlafaxine XR 37.5 mg PO qd|venlafaxine XR 75 mg PO qd|venlafaxine XR 150 mg PO qd|venlafaxine XR 37.5 mg PO qd|venlafaxine XR 225 mg PO qd"] [select name="sig3" value=" |Start|Continue|Stop|Increase|Decrease"] [select name="med3" value="|**SSRI**|fluoxetine 10 mg PO qd|fluoxetine 20 mg PO qd|fluoxetine 40 mg PO qd|fluoxetine 60 mg PO qd|---|escitalopram 5 mg PO qd|escitalopram 10 mg PO qd|escitalopram 20 mg PO qd|---|sertraline 25 mg PO qd|sertraline 50 mg PO qd|sertraline 100 mg PO qd|sertraline 150 mg PO qd|---|citalopram 10 mg PO qd|citalopram 20 mg PO qd|citalopram 40 mg PO qd|---|paroxetine 10 mg PO qd|paroxetine 20 mg PO qd|paroxetine 40 mg PO qd||**ANX/INS**|hydroxyzine 25 mg QID PRN|hydroxyzine 25-50 mg PO qHS PRN|Trazodone 50 mg PO qHS PRN|Trazodone 100 mg PO qHS PRN||**SNRI**|bupropion 150 mg XL po qd|bupropion 300 mg XL PO qd|bupripion 450 mg PO qd|---|venlafaxine XR 37.5 mg PO qd|venlafaxine XR 75 mg PO qd|venlafaxine XR 150 mg PO qd|venlafaxine XR 37.5 mg PO qd|venlafaxine XR 225 mg PO qd"] [select name="sig4" value=" |Start|Continue|Stop|Increase|Decrease"] [select name="med4" value="|**SSRI**|fluoxetine 10 mg PO qd|fluoxetine 20 mg PO qd|fluoxetine 40 mg PO qd|fluoxetine 60 mg PO qd|---|escitalopram 5 mg PO qd|escitalopram 10 mg PO qd|escitalopram 20 mg PO qd|---|sertraline 25 mg PO qd|sertraline 50 mg PO qd|sertraline 100 mg PO qd|sertraline 150 mg PO qd|---|citalopram 10 mg PO qd|citalopram 20 mg PO qd|citalopram 40 mg PO qd|---|paroxetine 10 mg PO qd|paroxetine 20 mg PO qd|paroxetine 40 mg PO qd||**ANX/INS**|hydroxyzine 25 mg QID PRN|hydroxyzine 25-50 mg PO qHS PRN|Trazodone 50 mg PO qHS PRN|Trazodone 100 mg PO qHS PRN||**SNRI**|bupropion 150 mg XL po qd|bupropion 300 mg XL PO qd|bupripion 450 mg PO qd|---|venlafaxine XR 37.5 mg PO qd|venlafaxine XR 75 mg PO qd|venlafaxine XR 150 mg PO qd|venlafaxine XR 37.5 mg PO qd|venlafaxine XR 225 mg PO qd"] [textarea name="freehand" default=""] Follow Up: [select name="follow" value="1 month or PRN|2 months or PRN|3 months or PRN"] Patient confirmed location and phone number as: [textarea name="variable_1" default=""] Patient agreed in event of emergency between visits are to be handled by going to their local emergency department, calling 911, or the suicide hotline. EMERGENCY CONTACT: [text name="em1" default=""] [/conditional][comment memo="New Patient"] [checkbox name="newpt" value=""][conditional field="newpt" condition="(newpt).is('')"] PHQ-9: [text name="phq" default=""] GAD-7: [text name="gad" default=""] DIAGNOSED: [checkbox name="dx" value="no hx mental health|depression|anxiety|ADHD|PTSD"] [text name="mhdx" default=""] TREATED WITH: [checkbox name="medhx" value="Never treated|Prior tx with"] [text name="txhx" default=""] SUICIDE ATTEMPTS: [checkbox name="sui" value="denies|remote history|recent history"] [text name="sui" default=""] SI: [checkbox name="si" value="denies|thoughts|without plan|fleeting|without intent"] [text name="si" default=""] SELF-HARMING: [checkbox name="harm" value="no hx self harming|remote history of self harming|current self harm"] [text name="harm" default=""] WEAPONS: [select name="weapons" value="Denies|Guns, locked, safely stored"] ETOH: [select name="ETOH" value="Denies use|Endorses occasional use (few drinks monthly)|A few drinks per week|Endorses frequent use (multiple times per week)|Endorses daily use"][text name="ETOH" default=""] Drug use: [select name="THC" value="Denies use|Reports use of THC|Endorses use,"] [text name="THC" default=""] EMPLOYMENT: [text name="work" default=""] LIVES WITH: [text name="lives" default=""] FH: [select name="fhx" value="no family hx|Family hx includes"] [text name="fhx" default=""] PMH: [checkbox name="pmh" value="Denies PMhx|HTN|HLD|DMII|Migraines|Asthma/Allergies|Hx of"] [text name="pmh" default=""] MEDS: [text name="currentmed" default="No current meds"] (DS CHECKED) S: Pt [select name="subwith" value="without history of mental health treatment|with history of mental health treatment"], [select name="submed" value="without history of taking medication|previously treated with ***"] seeking [select name="subdiscuss" value="consult to discuss potential treatment options|to refill precriptions"]. Reports [checkbox name="severity" value="worsening of symptoms|unchanging but persistant symptoms|symptoms are currently well controlled on medications"]. [checkbox name="lifechanges" value="Does report| changes in job|recent relationship changes|recent death of a loved one|relocation|it is unknown what may|have triggered a worsening of symptoms."] [textarea name="subj" default=""] Reviewed treatment typically 1 year when at goal to minimize relapse. Reviewed subscription model of service, and how to complete a follow up visit.Treatment discussed. Understands if unable to treat appropriately via our platform, to seek in person care. All patient's questions answered. Encouraged to follow-up with messaging if additional questions. Pt understands and agrees with plan. Explained detailed treatment plan regarding how to take the medication and potential side effects will be messaged in their Lemonaid account.Explained detailed treatment plan regarding how to take the medication and potential side effects will be messaged in their Lemonaid account. Discussed treatment-specific monitoring including most common side effects, appropriate usage/timing,[checkbox name="Consents" value="blood pressure monitoring for SNRIs|the benefit of counseling for PTSD treatment|the risk of NSAID use with MH medications|the use of ETOH with MH meds|the effect of THC on DA treatment|importance of consistency for most effective treatment"].[link url="https://www.soapnote.org/complete/lemonaid-visit-summary/" memo="Visit Summary"] [/conditional] [comment memo="Est Patient"] [checkbox name="espt" value=""][conditional field="espt" condition="(espt).is('')"] PHQ-9: [text name="phq2" default=""] (was [text name="phq3" default="]) GAD-7: [text name="gad2" default=""] (was [text name="gad3" default=""]) Suicidal ideations: [select name="si2" value="Denies|Endorses current"] [checkbox name="si2" value="thoughts|without plan|fleeting|without intent"] [text name="si2" default=""] Weapons: [select name="weapons" value="Denies|Guns, locked, safely stored"] EtOH: [select name="ETOH2" value="Denies use|Endorses occasional use (few drinks monthly)|A few drinks per week|Endorses frequent use (multiple times per week)|Endorses daily use"][text name="ETOH2" default=""] Drug use: [select name="THC2" value="Denies use|Reports use of THC|Endorses use,"] [text name="THC2" default=""] (DS CHECKED) S: FOLLOW UP Reports that medications [select name="working" value="are working well|are working ok|are not working"]. [select name="side" value="No noted side effects|Some side effects but tolerable. Side effects include|Endroses bothersome side effects including"] [checkbox name="sidefx" value="nausea|diarrhea|headache|fatigue|insomnia|increased anxiety|irritability|dizziness|decreased libido|weight gain|dry mouth"]. [select name="improvement" value="Improvement in overall mood and symptoms|Some improvement in mood and symptoms|No noticeable improvement in mood|Worsening of mood and symptoms"]. [select name="taking" value="Taking medication daily as prescribed|Missing some doses but overall compliant with medication|Has been out of medication|Stopped mediction due to side effects"]. [select name="sleep" value="Sleeping well|Sleeping poorly"]. Denies any red flag findings of depression/anxiety including mood swings, erratic behavior, suicidal ideation, or new/worsening anhedonia. [select name="contmed" value="Is pleased with current treatment plan. Would like to continue current medication|Finding some benefit but would like to increase dose|Would like to switch to a different agent|Has been stable and would like to start downward titration of medication"]. [textarea name="estnarr" default=""] Reminded patient to make follow up appointment when they are near the last 5 days of current treatment to avoid any days without medication.Treatment discussed. understands if unable to treat appropriately via our platform, to seek in person care. All patient's questions answered. Encouraged to follow-up with messaging if additional questions. Pt understands and agrees with plan. Explained detailed treatment plan regarding how to take the medication and potential side effects will be messaged in their Lemonaid account. Discussed treatment-specific monitoring including most common side effects, appropriate usage/timing, [checkbox name="Consents" value="blood pressure monitoring for SNRIs|the benefit of counseling for PTSD treatment|the risk of NSAID use with MH medications|the use of ETOH with MH meds|the effect of THC on DA treatment|importance of consistency for most effective treatment"].[link url="https://www.soapnote.org/complete/lemonaid-visit-summary/" memo="Visit Summary"][/conditional]
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Sandbox Metrics: Structured Data Index 0.64, 82 form elements, 22 text boxes, 4 text areas, 20 checkboxes, 26 drop downs, 2 links, 4 comments, 4 conditionals, 129 total clicks
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