SP

HISTORY OF PRESENTING PROBLEM[conditional field="A" condition="(A).is('Followup')"][comment memo="
99212 requires 1 HPI
99213 requires 1 HPI + pertinent ROS
99214 requires 4 HPI + pertinent ROS plus one other + 1 P/F/S hx
99215 requires 4 HPI + complete ROS + 2 P/F/S hx"][/conditional][conditional field="A" condition="(A).is('Intake')"][comment memo="
Intake = 90792"][/conditional]
[conditional field="A" condition="(A).is('Intake')"][/conditional]
The patient is a [text name="variable_1" default="sample text"] year old [checkbox name="variable_1" value="male |female |non-binary"] who presents to the clinic for [checkbox name="variable_1" value="an inital psychotherapy intake|follow-up psychotherapy appointment"]. The patient has a diagnosis of [checkbox name="variable_1" value="anxiety disorders |depression disorders |personality disorder | schizophrenia | attachment disorder | sleep disturbances | Bipolar | OCD | ADHD/ADD | PTSD | Eating disorder | mood disorder"]. The Patient remains [comment memo="SYMPTOM"][checkbox value="depressed|anxious|aggressive|impulsive|inattentive|irritable|withdrawn|unable to sleep|delusional|auditory hallucinations|visual hallucinations"][textarea memo="other" default="" rows="1"].
Which is described as[comment memo="SEVERITY "][checkbox value=" the same as it has been| better| somewhat worse than it has been| significantly worse than it has been"][textarea memo="other" default="" rows="1"]
The patient notices that it is sometimes improved by [comment memo="Modifying factors "][checkbox value="talking to someone|being alone|doing something physical like walking|doing something that is distracting"][textarea memo="other" default="" rows="1"]

*Review of Systems* [comment memo="Include for 99213 thru 99215"]
The patient identifies the following symptoms: [comment memo="Pertinent System "][checkbox value="irritability|mood instability|heightened anxiety|attention problems|troubled by hallucinations|fearfulness|nightmares|alcohol cravings|opiate cravings"][textarea memo="other" default="" rows="1"]
Other systems:
Neurological - [checkbox value="Headaches|weakness|disturbed sleep|denied"][textarea memo="other" default="" rows="1"]
GI - [checkbox value="Upset stomach|nausea|constipation|heatburn|denied"][textarea memo="other" default="" rows="1"]
[checkbox name="variable_1" value="Currently Denies SI/HI/Self-harm | Currently Denies SI/HI, endorses self harm |Currently denies HI, endorses SI/self-harm | Endorses SI, denies self-harm/HI"]
With:
[checkbox name="variable_1" value="with no plan or intent|has an active plan"]
All other systems negative

PHYSICAL EXAMINATION
Appearance: [select value="stated age|older than stated age|younger than stated age"], [select value="neat|disheveled"][textarea memo="other" default="" rows="1"]
Gait and Station / Muscle Strength and Tone: [select value="Steady gait while walking, normal strength bilaterally|"][checkbox value="unsteady gait while walking|clumsy|unable to ambulate|in bed|in wheelchair|assisted by cane|assisted by walker|rigid|spastic|normal strength bilaterally|weakness noted in "][textarea memo="other" default="" rows="1"]
Mood and Affect:
    Mood- [checkbox value="euthymic|depressed|anxious|angry|irritable|happy|fluctuating"][textarea memo="other" default="" rows="1"]
    Affect- [checkbox value="sad|tearful|anxious|flattened|restricted|irritable|happy|full range"][textarea memo="other" default="" rows="1"]
Speech: [select value="Normal rate and rhythm, not pressured|pressured|paucity"][textarea memo="other" default="" rows="1"]
Thought process: [select value="logical, linear, age appropriate|circumstantial|"][textarea memo="other" default="" rows="1"]
Associations: [select value="intact|loose|tangential|"][textarea memo="other" default="" rows="1"]
Thought Content: [select value="no evidence of delusions, |"][select value="no evidence of response to internal stimuli, |"][select value="no suicidal ideation or intentions, |"][select value="no homicidal ideation or intentions|"][textarea memo="other" default="" rows="1"]
Orientation: [select value="Oriented to person, place, and time|unable to assess due to cognitive impairment|"][textarea memo="other" default="" rows="1"]
Attention and Concentration: [select value="Adequate attention and concentration based on answers to interview questions|unable to assess due to cognitive impairment|impaired attention and concentration as evidenced by |"][textarea memo="other" default="" rows="1"]
Memory: [select value="Recent and remote memories both intact based on patient's answers to interview questions|unable to assess due to cognitive impairment"][textarea memo="other" default="" rows="1"]
Language: [select value="No evidence of aphasia |"][select value="|, able to name objects|[select value="|, able to repeat phrases"][select value="|unable to assess due to cognitive impairment"][textarea memo="other" default="" rows="1"]
Judgment and Insight:
    Judgment- [select value="fair|good|poor|impulsive"][textarea memo="other" default="" rows="1"]
    Insight- [select value="fair|good|poor"][textarea memo="other" default="" rows="1"]
Fund of Knowledge: Based on the answers to interview questions, patient's intelligence is judged to be [select value="average|above average|below average|unable to assess due to cognitive impairment"][textarea memo="other" default="" rows="1"]

[comment memo="Psychiatric Add On
Psychotherapy/Interactive Complexity/Prior case management
"][checkbox value="Time spent in psychotherapy: "][checkbox value="16-37 min"][comment memo="30 min 90833"][checkbox value="38-52 min"][comment memo="45 min 90836"][checkbox value="53-67 min"][comment memo="60 min 90838"]
[checkbox value="Focus of psychotherapy: "][checkbox value="interpersonal conflict|emotional experience related to diagnosis|identification of coping mechanisms|grief counseling"][textarea memo="other" default="" rows="1"]
[checkbox value="Modality: "][checkbox value="insight oriented|supportive|behavioral modification"][textarea memo="other" default="" rows="1"]

REVIEW/MANAGEMENT
*Problem Status*[comment memo="
Problem status: Established-stable/improved=1pt each 
Established-worsening=2pt each 
New problem, no additional workup planned=3pt (only one) 
New problem, additional workup planned=4pt"]
The patient's progress in achieving treatment goals can best be characterized as: [checkbox value="minimal|patient is resistant|patient is making some progress|patient is working on goals, but remains symptomatic"][textarea memo="other" default="" rows="1"]


Diagnosis:[comment memo="Indicate whether diagnosis changed, reason for change, date and time of change"][checkbox value="
Major depressive disorder|recurrent|single episode|mild|moderate|severe|
Generalized anxiety disorder|
PTSD|acute|chronic|
Adjustment Disorder|with depressed mood|with anxiety|with depressed mood and anxiety"]
[textarea rows="5"]

ASSESSMENT
Patient is currently displaying [select value="symptoms of|well managed|moderately managed|poorly managed"] [checkbox value="depression|anxiety|sleep disturbance|psychosis|substance abuse|cognitive impairment|impulsivity|mood lability|alcohol dependence|opiate dependence|autism spectrum disorder"][textarea memo="other" default="" rows="1"] which is [select value="likely caused by|likely exacerbated by|likely the result of"] [checkbox value="their unmanaged depressive disorder|their unmanaged anxiety disorder|their unmanaged bipolar disorder|interpersonal/family conflict|current psychopharmaceutical intervention|current psychotherapy|current psychosocial support systems"][textarea memo="other" default="" rows="1"]. Patient would benefit from [checkbox value="continuation of current psychotherapy | continued psychopharmaceutical intervention|adjustments to current psychopharmaceutical intervention|engaging in grief therapy|engaging in CBT|engaging in family therapy|enhanced psychosocial supports|increasing personal time and self-care"][textarea memo="other" rows="1"]. Prognosis is [select value="good|fair|poor"] considering the patient [select value="remains adherent to|actively engages in|is not currently responding to"] medication/therapy to address [textarea memo="target of treatment" rows="1"][checkbox value=" and whether they are able to engage constructively with social supports"]. [checkbox value="Barriers to success include: "][checkbox value="current apprehension to engage in psychopharmaceutical intervention|current apprehension to engage in structured psychotherapy|current emotional distress of recent cancer diagnosis|limited social supports|dysfunctional interpersonal relationships"][textarea memo="barriers" rows="1"]. [checkbox value="Patient strength for success include: "][checkbox value="expression of willingness to engage in treatment recommendations|positive social supports|are well connected with outpatient supports|history of actively engaging in mental-health treatment"][textarea memo="strengths" rows="1"].  [textarea rows="5"]

PLAN:
[text name="variable_1" default="-Continue working with Psychiatrist for SSRI
-The patient a demonstrated her journal taking during therapy and agreed to continue in journaling/reflective note-taking as discussed in the session, create a daily routine to encourage self-care, behavioral activation, and organization; consistently commit to daily routine/behavioral activation schedule
-The patient will continue to think about joining the CBT group therapy
-Follow Up in 1 weeks for continued psychotherapy
-The patient will contact emergency services for after hour cares 
-Discussed coping mechanisms and patient agreed to work on taking a step back and thinking before reacting"]