NPNE Residential Detox Note [UTD 11.26.24]
Reason for visit/Chief Complaint: Daily monitoring during detox per protocol SUBJECTIVE: Admit date: [date name="variable_1" default=""] [select name="variable_lastnamepronoun" value="Mr.|Ms.|Mx."] [text name="variable_ptname" default=""] is admitted for medically managed detoxification and subsequent residential substance use treatment for [checkbox name="sud" value="alcohol use|amphetamine use|methamphetamine use|cannabis use|synthetic cannabis use|sedative use|benzodiazepine use|hypnotic use|anxiolytic use|stimulant use|opioid use|codeine use|heroin use|fentanyl use|oxycodone use|kratom use|phenibut use|crack use|xanax use|ativan use|cocaine use|adderall/vyvanse/ritalin use|hallucinogens use|MDMA use|Ketamine use|inhalants use|other psychoactive substances|polysubstance use"] secondary to the inability to maintain sobriety independently. --- Interval Medical History: Withdrawal scores:[text name="variable_wds" default=" CIWA/ COWS"]; [select name="variable_trend" value="|trend is waxing and wanning|trend is stagnant| trend is improving| trend is worsening|trend is fluctuating"] Withdrawal symptoms: [checkbox name="variable_wdsxs" value="denies|anxiety|nausea|vomitting|headache|hypertension|clouded sensorium|malaise|muscle pain|abdominal pain|sweating|constipation|GI upset|diahrrea|elevated HR|blunted sensorium|fatigue|irritability|cravings|tremors|sleep disturbances"][textarea name="variable_ciw" default=""] [checkbox memo="Protocol CIWA" name="If_detox1" value=""][conditional field="If_detox1" condition="(If_detox1).is('')"]AUD/SUD Protocol: [checkbox name="continued" value="[checkbox name="detoxdrug" value="Librum taper|Ativan taper|Suboxone|Valium taper|Ativan PRN|Gabapentin|Tegretol taper|Valium PRN|Administer meds assigned for symptomatic treatment associated with detox"] [checkbox name="variable_23332" value="This patient is on taper day"] [text name="variable_tap" default=""][/conditional] [checkbox memo="If opioids" name="If_detox2" value=""][conditional field="If_detox2" condition="(If_detox2).is('')"]MOUD Protocol: Last Opioids (approximately) [text name="variable_ops" default=""] [select name="variable_1time" value="hours ago|days ago"] of [select name="variable_op2" value="long-acting opioid|short-acting opioid"] Protocol: [checkbox name="continued2" value="[checkbox name="detoxdrug" value="Suboxone induction|Suboxone maintenance|Gabapentin|Tegretol taper|Administer meds assigned for symptomatic treatment associated with detox"][/conditional] [checkbox name="medcc1" value="- Acute Medical Concerns: denies any acute medical concerns"] [checkbox name="medcc2" value="- Health Status: denies any changes to their current health status"] [checkbox name="medcc3" value="- Medication Side Effects: denies any ADR or side effects to medications"] [checkbox name="medcc9" value="- Medication Side Effects: endorses any side effects to medications"] [checkbox name="medcc5" value="- Reported Concerns: no reported complaints by staff regarding patient"] [checkbox name="medcc6" value="- Medication Adherence: reported adherence"] [checkbox name="medcc7" value="- Medication Adherence: reported nonadherence"] [checkbox name="medccMAT" value="- Medication Assisted Treatment: currently rx'd MAT"] [checkbox name="medccMAT2" value="- Medication Assisted Treatment: not currently rx'd MAT"] [checkbox name="medcc8" value="Updates on the progress of previously identified health issues include:"] [checkbox name="medcc011" value="Changes in medication/treatment plan include:"][textarea name="concerns" default=""] [select name="variable_12427" value="|- Safety: This patient is currently on a risk precaution for"] [checkbox name="variable_1" value="fall risk| seizure risk| suicide risk|self-harm risk|AMA risk"]. [checkbox name="variable_riskfs" value="This patient has not had any incidences regarding this risk factor.|This patient has had any incidences regarding this risk factor"] [checkbox memo="Quick Recovery Note" name="If_qrn" value=""][conditional field="If_qrn" condition="(If_qrn).is('')"] - Psychiatric Symptoms: Reports their depression is [select name="depression" value="|low|minimal|variable|manageable|medium|moderate|high|stable|episodic|present, but stable|present and unstable|unstable|stagnant|significantly better|somewhat better|somewhat worse|much worse|0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"]; reports their anxiety is [select name="anxiety" value="|low|minimal|variable|manageable|medium|moderate|high|stable|episodic|present, but stable|present and unstable|unstable|stagnant|significantly better|somewhat better|somewhat worse|much worse|0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"]. - Sleep Disturbances: Reports their sleep is [select name="sleep" value="stable|unstable|stagnant|significantly better|somewhat better|somewhat worse|much worse|"] [select name="sleepprob" value="|without any nightmares, interruptions, or dreams of substance use|with difficulties falling asleep|with difficulties with frequent awakenings|with difficulties staying asleep| difficulties with nightmares|with restless legs|with sleep apnea|with detox symptoms"]. - Cravings: noted to be [select name="variable_cr" value="moderate due to both external and internal triggers|minimal due to being in a protected environment and manageable with coping skills|minimal due to being in a protected environment and manageable with coping skills and MAT"]. [checkbox memo="SI/HI/AVH" name="If_asci" value=""][conditional field="If_asci" condition="(If_asci).is('')"] - SI/SH/HI/AVH: Patient [select name="variable_si2" value="denies|endorses"] [select name="variable_si3" value="suicidal ideation|passive suicidal ideation|current hallucinations|suicidal and homicidal ideation|suicidal and homicidal ideation| hallucinations|paranoia|hallucinations and paranoia| active suicidal ideation| active suicidal ideation without intent or plan| active suicidal ideation with plan and without intent| homicidal ideation| self-harm ideation without the intent to die|"] [/conditional] [/conditional] [checkbox memo="RECOVERY PROGRESS" name="If_rp" value=""][conditional field="If_rp" condition="(If_rp).is('')"] Recovery Progress: During examination, this patient [select name="variable_6" value="is polite and cooperative|interactive|has limited in their engagement with this conversation|is polite, but has limited engagment in this conversation|is withdrawn|is guarded|is hostile|is questioning|is demanding|is agitated|is anxious|is tearful|is manic|is dysregulated|is dysthymic|is euthymic|is irritable"]. - Depressive symptoms: Reported to be [select value="low|minimal|variable|manageable|medium|moderate|high|stable|present, but stable|present and unstable|unstable|stagnant|significantly better|somewhat better|somewhat worse|much worse|"]. [select value="||This could be attributed to|Current stability is attributed to|Current instability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to |"] [checkbox value="the continuation of current medications|the recent medication changes|dissatisfaction with medications|the positive response to medications|the lack of response to medications|situational stressors|situational stressors related to family|finanicial stressors|legal stressors|in-home stressors|in-facility stressors|home sickness|loneliness|grief|trauma|the adjustment to the environment|the incorporation of self-care|engaging with peers|engaging in individual therapy|engaging in group therapy|practicing coping skills|practicing TIPP skills|practicing STOP skills|practicing breathing excersise|the lack of application of coping skills|the lack of knowledge of coping skills|cravings for substances |abstaining from substance use|return to inpatient care|detox symptoms|post-acute withdrawal symptoms|decline in mental health|decline in physical health|improvement in mental health|improvement in physical health|changes in sleep patterns|lack of sleep|pain|upcoming discharge|discharge plan|unable to assess"]. [select name="variable_si" value="|Patient denies SI.| Patient endorses SI without plan or intent.| Patient endorses SI with plan.| Patient endorses self harming thoughts."] - Anxiety symptoms: Reported to be [select value="low|minimal|variable|manageable|medium|moderate|high|stable|episodic|present, but stable|present and unstable|unstable|stagnant|significantly better|somewhat better|somewhat worse|much worse|"]. [select value="||This could be attributed to|Current stability is attributed to|Current instability is attributed to|Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "] [checkbox value="the continuation of current medications|the recent medication changes|dissatisfaction with medications|the positive response to medications|the lack of response to medications|situational stressors|situational stressors related to family|finanicial stressors|legal stressors|in-home stressors|in-facility stressors|home sickness|loneliness|grief|trauma|the adjustment to the environment|the incorporation of self-care|engaging with peers|engaging in individual therapy|engaging in group therapy|practicing coping skills|practicing TIPP skills|practicing STOP skills|practicing breathing excersise|the lack of application of coping skills|the lack of knowledge of coping skills|cravings for substances |abstaining from substance use|return to inpatient care|detox symptoms|post-acute withdrawal symptoms|decline in mental health|decline in physical health|improvement in mental health|improvement in physical health|changes in sleep patterns|lack of sleep|pain|upcoming discharge|discharge plan|unable to assess"]. Anxiety is reported to be present [select value="occasionally.|mostly around situational stressors.|almost never.|about 50% of the time.|about 50-80% of the time.|most of the time on most days.|almost always.|"] - Sleep is reported to be [select value="stable|unstable|stagnant|significantly better|somewhat better|somewhat worse|much worse|"]. [select value="|without any nightmares, interruptions, or dreams of substance use|This could be attributed to|Current stability is attributed to|Current instability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | with difficulties falling asleep| with difficulties with frequent awakenings|with difficulties staying asleep|with difficulties with nightmares|with difficulties with oversleeping"] [checkbox value="the continuation of current medications|the recent medication changes|the lack of response to medications|the positive response to medications|anxiety|legal issues|situational stressors|detox symptoms|the adjustment in sleep environment|lifestyle improvements|engaging in individual therapy|pain|upcoming discharge|with sleep hygiene education"][textarea]. - Focus: [select name="variable_f123" value=" Patient reports adequate focus during groups|Patient reports adequate focus during groups and with peers|Patient reports poor attention and concentration in conversations with peers and staff| Patient reports poor attention and concentration in groups|Patient reports difficulty concentrating throughout the day|Patient reports poor attention and concentration in groups|Patient reports having difficulty with memory|Unable to assess|Unable to assess due to poor group attendance"]. - Cravings: [select name="variable_cr" value="cravings are moderate due to both external and internal triggers|cravings are minimal due to being in a protected environment and manageable with coping skills|cravings are minimal due to being in a protected environment and manageable with coping skills and MAT"] - Appetite: [select name="variable_ap" value="denies any changes or concerns with appetite|reports poor appetite| nutritionally deficient|reports flucuation in appetite| reports eating disorder disturbance|reports eating greater than 50% of each meal| reports eating less than 50% of each meal| reports bulimic episodes AEB vomitting after eating|reports restricting diet|reports eating snack and meals daily"] [/conditional] -- [checkbox memo="Chronic Care" name="If_cci" value=""][conditional field="If_cci" condition="(If_cci).is('')"]Past Medical History: [textarea name="variable_knowme" default=""] [comment memo="COMMON STATEMENTS: - current treatment: - reported concerns: - response to treatment: - updates to treatment: - no acute findings - Pending lab findings to inform further management - Pending lab findings to determine current health status - Pending lab findings to determine current health status and inform further management - Chronicity and stability established in previous notes, no further management needed at this time. Revisit plan of care if exacerbation occurs"] [remark memo="Replace word NUMBER with numeral in field names chrNUMBER, controlNUMBER, symptomsNUMBER, currenttxNUMBER, prevtxNUMBER, ptxNUMBER1, ptxNUMBER2, ptxNUMBER3, medtxNUMBER, MedSideEffectsNUMBER, dxreqNUMBER, SatisfiedNUMBER, OtherSpecsNUMBER, and OtherDetailsNUMBER "] [checkbox memo="#NUMBER" memo_size="small" name="chrNUMBER" value="-Chronic Condition-"][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"][comment memo="-------------BEGIN CONDITION NUMBER-------------"][comment memo_size="small" memo_color="blue" memo="select one ▼▼"][frontload soapnote="sample/drgfms-include-condition-dropdown/"] - [textarea memo="◀︎◀︎ and/or freetext" memo_size="small" memo_color="blue" rows="2" cols="50"] - Patient reports that the condition is [select name="controlNUMBER" value="well controlled|not well controlled|stable|unchanged from last visit|improved from last visit|worse than at last visit"] - Currently, [select name="symptomsNUMBER" value="the patient notes there are no symptoms.|symptoms are present including"][/conditional][conditional field="symptomsNUMBER" condition="(symptomsNUMBER).is('symptoms are present including')"] [checkbox value="pain|fatigue|shortness of breath|palpitations|nausea|vomiting|abdominal pain|urinary symptoms"][text default="."] [/conditional][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"][checkbox name="currenttxNUMBER" memo="current treatment" value=""][/conditional][conditional field="currenttxNUMBER" condition="(currenttxNUMBER).is('')"] - Current treatments include [select name="medtxNUMBER" value="no medications.|medications including "][/conditional][conditional field="medtxNUMBER" condition="(medtxNUMBER).is('medications including ')"][textarea]. [select name="MedSideEffectsNUMBER" value="The patient denies side effects|The patient complains of side effects including "][/conditional][conditional field="MedSideEffectsNUMBER" condition="(MedSideEffectsNUMBER).is('The patient complains of side effects including ')"][checkbox value="|shortness of breath|dysnpea on exertion|orthostasis|diaphoresis|dizziness|drowsiness|vision changes|headache|dry mouth|sore throat|chest pain|palpitations|back pain|diahrrea|constipation|skin rash|insomnia|nausea|abdominal pain|vomitting|suicidal thoughts|anxiety|malaise"][textarea cols="50" rows="2" memo_size="small" memo_color="blue" memo="◀︎◀︎ include more here."][comment memo_size="small" memo_color="blue" memo=" Add a space/comma/period in front, as appropriate, if any above are selected"].[/conditional][conditional field="currenttxNUMBER" condition="(currenttxNUMBER).is('')"] [select name="othertxNUMBER" value="No other treatments are noted.|Additional treatments include "][/conditional][conditional field="othertxNUMBER" condition="(othertxNUMBER).is('Additional treatments include ')"][textarea cols="50" rows="2"]. [/conditional][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"][checkbox name="prevtxNUMBER" memo="previous treatments" value=""][/conditional][conditional field="prevtxNUMBER" condition="(prevtxNUMBER).is('')"] -Previous treatments include [checkbox name="ptxNUMBER1" value=" -#1 - "][/conditional][conditional field="ptxNUMBER1" condition="(ptxNUMBER1).is(' -#1 - ')"][text size="60"], reason discontinued [checkbox value="intolerable side effects|no improvement"][textarea memo="other reason" memo_size="small" memo_color="blue"] [/conditional][conditional field="prevtxNUMBER" condition="(prevtxNUMBER).is('')"][checkbox name="ptxNUMBER2" value=" -#2 - "][/conditional][conditional field="ptxNUMBER2" condition="(ptxNUMBER2).is(' -#2 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][textarea memo="other reason" memo_size="small" memo_color="blue"] [/conditional][conditional field="prevtxNUMBER" condition="(prevtxNUMBER).is('')"][checkbox name="ptxNUMBER3" value=" -#3 - "][/conditional][conditional field="ptxNUMBER3" condition="(ptxNUMBER3).is(' -#3 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][textarea memo="other reason" memo_size="small" memo_color="blue"] [/conditional][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"][checkbox memo="patient requests/needs diagnostic or lab tests" name="dxreqNUMBER" value=""][/conditional][conditional field="dxreqNUMBER" condition="(dxreqNUMBER).is('')"] - Patient [select value="needs|is due for|requests"] diagnostic testing including [comment memo_size="small" memo_color="blue" memo="select any number from below ▼▼"][checkbox value="CBC|CMP|Fasting Lipids|A1c|gout/uric acid labs|Thyroid labs|TSH|Free T4|Vitamin B12|Vitamin D|lupus labs|rheumatoid arthritis labs|lyme disease labs|RMSF labs|COVID-19 antibodies|COVID-19 nasopharyngeal swab|STI testing|X-ray|CT|MRI|Ultrasound"][textarea cols="50" rows="2" memo_size="small" memo_color="blue" memo="◀︎◀︎ include more here."][comment memo_size="small" memo_color="blue" memo=" Add a space/comma/period in front, as appropriate, if any above are selected"]. [/conditional][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"][checkbox memo="Other specialists comanage the condition" name="OtherSpecsNUMBER" value=""][/conditional][conditional field="OtherSpecsNUMBER" condition="(OtherSpecsNUMBER).is('')"] - Other specialists comanaging - [textarea rows="2" cols="50"][/conditional][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"][checkbox memo="Other details" name="OtherDetailsNUMBER" value=""][/conditional][conditional field="OtherDetailsNUMBER" condition="(OtherDetailsNUMBER).is('')"] [textarea default=""][/conditional][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"][checkbox memo="Patient satisfied with treatment" name="PtSatisfied" value=""][/conditional][conditional field="PtSatisfied" condition="(PtSatisfied).is('')"] - Pt [select name="SatisfiedNUMBER" value="|is|is not"] satisfied with current management[/conditional][conditional field="SatisfiedNUMBER" condition="(SatisfiedNUMBER).is('is not')"]; [text memo="details" size=60].[/conditional][conditional field="SatisfiedNUMBER" condition="(SatisfiedNUMBER).is('is')"].[/conditional][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"] [comment memo="--------------END CONDITION NUMBER--------------"][/conditional][/conditional] [checkbox memo="Acute Issues" name="If_aci" value=""][conditional field="If_aci" condition="(If_aci).is('')"] Acute Issues: [textarea name="variable_2045" default=""] [/conditional] ____________________________________ Review/ Management: I reviewed the following information: medical hx, medications, allergies, physical exams and progress notes, V/S I obtained collateral information from: [checkbox name="variable_who" value="nursing|psychiatry|counselors|leadership"] _________________________________________ ROS: Pertinent Neg and Pos discussed in HPI ___________________________________________ OBJECTIVE: Physical examination: [VSS and patient asymptomatic] Constitutional: cooperative, [select name="variable_general" value="in no acute distress|intoxicated|fatigue| anxious appearing| restless| agitated| guarded"], [select name="variable_3" value="well-kempt|poorly kempt|appropriately dressed|inappropriately dressed|appropriately groomed|inappropriately groomed| appears stated age| appears older than stated age| appears younger than stated age| poor nutritional appearence| under-nourished| well-nourished"] Neuro: [select name="variable_neuro" value="A&O| A&Ox1|A&Ox2|A&Ox3|unable to determine|neurocognitive deficit seen| fatigue"] Respiratory: lung sounds clear, no accessory muscle use Cardiac: RRR, no m/r/g, [select name="variable_edema" value="no edema|+1 edema|+2 edema| pitting edema present"] GI: abdomen soft, non-distended, non-tender. Bowel tones normoactive Psych: [select name="variable_8" value="calm and cooperative||calm|normal|upbeat|euthymic|depressed|dysthmic|neutral|anxious|hostile|irritable|tearful"] ASSESSMENT/PLAN: Impression: This patient was admitted for medically managed detox and subsequent residential services [checkbox name="variable_147" value="secondary to the inability to maintain sobriety independently"]. [select name="variable_time" value="Since admission|Over this last week|Over the last 24 hours|"], [select name="variable_howdo" value="this patient's clinical improvement is still in progress|this patient is pending clinical improvement||this patient's clinical improvement has been achieved|there has been minimal clinical improvement|there has been minimal clinical improvement due to resistence|this patient's clinical improvement has plateaued"]. # Detoxification [checkbox memo="Anticipated complications" name="bs" value=""] [conditional field="bs" condition="(bs).is('')"][checkbox value="Anticipated complications include "][checkbox value="severe withdrawal symptoms|dehydration|malnutrition|electrolyte imbalance|sleep distruption|emotional distress|cardiovascular issues|post-acute withdrawal symptoms (PAWS)|risk of relapse|none identified"][/conditional] [checkbox memo="Current withdrawal complications" name="If_ETOH" value=""][conditional field="If_ETOH" condition="(If_ETOH).is('')"]Current complications include [checkbox name="variable_compl" value="none identified|severe withdrawal symptoms|dehydration|malnutrition|electrolyte imbalance|sleep distruption|emotional distress|cardiovascular issues|recent seizure activity|electrolyte imbalance|reported decrease renal function|acute kidney injury|liver disease|disorentation|persistent psychiatric illness|alcoholic hepatitis|transaminitis"][/conditional] [checkbox memo="If opioids" name="If_detox3" value=""][conditional field="If_detox3" condition="(If_detox3).is('')"] [checkbox memo="Initiation" name="If_detox4" value=""][conditional field="If_detox4" condition="(If_detox4).is('')"] MOUD Tx: -- [checkbox name="variable_mouds3" value="Patient has met criteria to start MOUD|Patient has NOT met criteria to start MOUD|Patient has declined start MOUD"] [checkbox memo="No Initiation" name="If_detox84" value=""][conditional field="If_detox84" condition="(If_detox84).is('')"] -- [select name="variable_14752" value="Nursing to monitor CWS; if subsequent CWS after admission are >13; consider starting MOUD"][/conditional] [checkbox memo="Initiation" name="If_detox74" value=""][conditional field="If_detox74" condition="(If_detox74).is('')"] -- [select name="variable_14526732" value="Begin buprenorphine-naloxone induction with 2mg/0.5mg|Begin buprenorphine-naloxone induction 4mg/1mg "] every [text name="variable_hrs" default="4"] hours -- [checkbox name="variable_45" value="Plan for patient to use total dose of 12mg/3mg per day|Plan for patient to use total dose of 16mg/3mg per day"] [checkbox name="variable_120" value="-- Given their prior dose of opioid use, may need higher dose. Will follow closely"][/conditional] [checkbox memo="Maintenance" name="If_detox5" value=""][conditional field="If_detox5" condition="(If_detox5).is('')"] -- Continue buprenorphine-naloxone [text name="variable_bup" default="4mg/1mg TID"] for stabilization/maintenance phase of treatment [/conditional] -- Discussed potential side effects and their management. Osmotic stool softener for constipation. (Miralax) -- Patient instructed in proper use of medication and long-term treatment per practice protocol. [/conditional] [/conditional] [textarea name="variable_detox22" default="- Medication Management: Continue medication for withdrawal symptom management and provide PRN medications as indicated for symptom management - Monitoring: Monitor for s/s of withdrawal and CWS/CIWA scores - Patient Educatoion: Educate on withdrawal process, detox protocol, medications - Outings: Patient may attend outings at the discretion of the provider"] [checkbox name="variable_155" value="- Assessment changes: Revised nursing assessment frequencies"] # Substance use treatment - Structured Environment: This patient continues to reasonably benefit from admission in a protected and structured environment to prevent relapse via medical and mental health support, medication management, therapeutic interventions and education, skill development and holistic therapies. - Monitoring: Continue to monitor recovery in a protected environment -Therapeutic Engagement: Encourage to engage in group sessions, individual therapy sessions, and outings per treatment plan - Psychiatric Coordination: Coordinate treatment with the psychiatric team - Relapse Prevention: Encourage engagement in ongoing relapse prevention and aftercare plan [checkbox memo="Craving Medications" name="If_MATnow" value=""][conditional field="If_MATnow" condition="(If_MATnow).is('')"] - Craving Management:[checkbox name="variable_MATnows" value="none|pending education|still deciding|declined all options|naltrexone PO| naltrexone PO with subsequent vivitrol injection on discharge|acamprosate|not applicable|gabapentin|topirmate|naltrexone PO and acamprosate|naltrexone with subsequent vivitrol injection on discharge and campral| previously completed naltrexone| previously completed acamprosate| previously completed vivitrol|suboxone|suboxone with subsequent sublocade injection|discussed off-label use of medications to aid with cravings; pending decision|discussed off-label use of medications to aid with cravings; pt accepted|discussed off-label use of medications to aid with cravings; pt declined|will plan to d/c with naloxone"] [/conditional] [checkbox name="variable_labsadmit" value="- Diagnostics: Pending admission lab results to assess overall health status and guide treatment plan"] [checkbox memo="Admission Labs" name="labs" value=""][checkbox memo="MAT" name="mat" value=""] [checkbox memo="Liver Conditions" name="If_liver" value=""][conditional field="If_liver" condition="(If_liver).is('')"] # [select name="LD" value=" ||Elevated liver enzymes|Fatty liver disease| Liver disease| Alcoholic Hepatitis| Hepatitis C| Hepatitis B| Alcoholic Liver Disease| Cirrhosis| Pancreatitis|Viral Hepatitis|Liver cancer| Gallbladder disease"] [checkbox name="LD" value="- No acute concerns note on follow up"][checkbox name="LDinfo" value="- Chronicity and stability established on admission, no further management needed at this time. Revisit plan of care if exacerbation occurs"][checkbox name="LDnoinf" value="- Pending lab findings to determine current health status and inform further management"] [checkbox name="variable_125" value="- Acute findings include:"][text name="variable_1252" default=""] [checkbox name="LDavoid" value="- Avoid drugs that cause hepatocellular injury and cholesteric abnormalities"][checkbox name="variable_folw" value="- Follow up with PCP upon discharge"][/conditional] [checkbox memo="Hypertension" name="If_htn" value=""][conditional field="If_htn" condition="(If_htn).is('')"]# [select name="HTN" value=" |Hypertension|Elevated BP without a dx of HTN|Congestive heart failture| Heart disease"] Health status: [select name="variable_stable" value="|-- stable BP, asymptomatic|-- unstable BP, asymptomatic|-- unstable BP, symptomatic|-- stable BP, symptomatic"] Monitoring: [checkbox name="htnplannurse" value="-- Nursing to complete V/S checks as indicated by the provider or protocol"] [checkbox name="htnplan" value="-- Patient is going through acute withdrawal from ETOH; pt blood pressures will be labile"] Medication: [checkbox name="htnplancont" value="-- Continue MAR medications"][text name="variable_1428" default=""] [checkbox name="htnplanstart" value="-- Treatment adjustments:"][text name="variable_medst" default=""] [checkbox name="htnplanmedno" value="-- Patient is not on medications"] Follow up: [checkbox name="htnplanfu" value="-- Follow up with PCP upon discharge"][/conditional] [checkbox memo="Diabetes" name="If_dm22" value=""][conditional field="If_dm22" condition="(If_dm22).is('')"]# [select name="DM" value=" |Type 2 diabetes mellitus without complications|Type 2 diabetes mellitus with hyperglycemia|Type 1 diabetes mellitus without complications|Type 1 diabetes mellitus with hyperglycemia|Other specified diabetes mellitus|Prediabetes"] Health status: [checkbox name="dmplangoa1" value="-- BG WNL"] [checkbox name="dmplangoal" value="-- e/o hyperglycemia|-- e/o hypoglycemia episodes"] [checkbox name="dmplannogo" value="-- Chronicity and stability established on admission"] Medication: [checkbox name="dmplanmedno" value="-- Continue current medications"] [checkbox name="dmplanmedn2o" value="-- Medications adjusted:"][textarea name="variable_1dm" default=""] [checkbox name="dmplanmedno" value="-- Patient is not on medications"] Monitoring: -- [select name="variable_1520z" value="|Monitor BG QIDAC+HS|Monitor BG BID|Monitor BG TID|Monitor BG QID|Monitor BG QD|Monitor BG Q Weekly"] [checkbox name="variable_2202xs" value="-- Patient is electing not to monitor blood glucose"] Follow up: [checkbox name="variable_103xcv" value="-- Follow up if exacerbation occurs"] [checkbox name="dmplanfu" value="-- Patient should follow up with PCP after discharge"] [/conditional] [textarea name="medPOC" default=""] [comment memo="COMMON STATEMENTS: - no acute findings - Pending lab findings to inform further management - Pending lab findings to determine current health status - Pending lab findings to determine current health status and inform further management - Chronicity and stability established in previous notes, no further management needed at this time. Revisit plan of care if exacerbation occurs -The patient's progress and medication needs will be continuously monitored and adjusted as necessary - Follow up with PCP upon discharge"] [checkbox memo="Psychiatric Conditions" name="If_psychpoc" value=""][conditional field="If_psychpoc" condition="(If_psychpoc).is('')"]# [text name="variable_psychillnes" default="Depression"] - Continue management by the psychiatric provider - Monitor for any changes in the patient's mood, behavior, or suicidal ideation. - Follow-ups determined by the psych provider to monitor patient's condition and response to treatment. [checkbox name="variable_1425" value="- Continue medications as indicated on MAR"] [textarea name="variable_psyhf8" default=""][/conditional] [checkbox memo="Suicide Risk" name="If_sic" value=""][conditional field="If_sic" condition="(If_sic).is('')"][select name="sxsicurrent" value="|# Suicidal ideation|# Recent suicide attempt|# Self-harm ideation|# Recent self-harm attempt"] - Continue suicide screening qshift - Monitor for any changes in the patient's mood, behavior, or suicidal ideation[/conditional] [checkbox memo="Seizure Management" name="If_sz" value=""][conditional field="If_sz" condition="(If_sz).is('')"]# [select name="sxhx" value="|Seizure management|History of seizure-like activity|Other seizure| Convulsions|Seizure History|Alcohol withdrawal seziure| Pseudo-seizure|Non-epileptic behavioral event|"] [checkbox name="variable_szcurrnt" value="- No incidences of seizures"] [checkbox name="variable_sxhxss" value="- If a seizure were to occur then acute management of the seizure should be concomitant with ABCs, avoiding hazards, and monitoring vital signs & glucose monitoring. Nursing advised to call provider if this occurs; call EMS if decompensation occurs|- Nursing to monitor CIWAs/CWS and Vitals"] [checkbox name="variable_sxhxr" value="- Medications Rx'd to aid with alcohol withdrawal seizures|- Medications Rx'd to aid with seizure prophylaxis|- No medications prescribed currently"][/conditional] [checkbox memo="Sleep Management" name="If_sep" value=""][conditional field="If_sep" condition="(If_sep).is('')"] [select name="variable_2024slep" value="# Sleep Management|# Insomnia"] [checkbox name="variable_sep1" value="- Patient has declined sleep medications"] [checkbox name="sleepad" value="- Treatment adjustments:"][text name="variable_med342" default=""][/conditional] [conditional field="labs" condition="(labs).is('')"] # ADMISSION LABS - see progress note for interpretation - see PHI for lab results - labs reviewed with patient[/conditional] [conditional field="mat" condition="(mat).is('')"] [select name="variable_2223" value="# Medication-Assisted Treatment|# Cravings|choice C"] The risk and benefits of this MAT medications have been explained to this patient. This patient has been provided education regarding this medication. This patient would benefit from [checkbox name="variable_22" value="naltrexone|Vivitrol|acamprosate"]. [select name="variable_236" value="This patient declines MAT at this time| This patient accepts Naltrexone PO at this time|This patient accepts Naltrexone/ Vivitrol at this time| This patient is still deciding on MAT| This patient accepts acamprosate"] [/conditional] Disposition: [select name="variable_202475" value="- Status/Safety: Continue patient on detox status with 15 minute safety checks|- Status/Safety: Transition patient to residential 1 status with 60 minute safety checks|- Status/Safety: Transition patient to residential 1 status with 15 minute safety checks|- Status/Safety: Transition patient to residential 2 status with 60 minute safety checks|- Status/Safety: Transition patient to residential 2 status with 15 minute safety checks"] - Health Team Coordination: Continue psychiatric-medical team collaboration, and update interdiscplinary team. - Discharge Planning: Upon discharge, the patient should maintain continuity of care with their primary care provider or establish care if one is not already in place. Any necessary specialist follow-ups should also be arranged
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Sandbox Metrics: Structured Data Index 0.81, 248 form elements, 291 boilerplate words, 16 text boxes, 19 text areas, 1 dates, 100 checkboxes, 52 drop downs, 8 comments, 1 remarks, 50 conditionals, 1 frontloads, 455 total clicks
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