Adult Follow Up Office

[date name="date2" default="timestamp"] central time

This Patient’s Last Video Visit with a Provider was on [date name="variable_89" default=""]

[text name="name" memo="Patient name" size="20"] is a [select name="age" value="|18|19|20|21|22|23|24|25|26|27|28|29|30|31|32|33|34|35|36|37|38|39|40|41|42|43|44|45|46|47|48|49|50|51|52|53|54|55|56|57|58|59|60|61|62|63|64"] years-old, [select name="race" memo="race" value="|white|black|asian"],[select name="gender" memo="gender" value="|cis-gender female|cis-gender male|transgender female|transgender male|gender non-binary individual"]

History of Presenting Illness:
[var name="name"] that [select value="was informed of the limitations of telemedicine |paresents in this outpatient appointment "][select value="alone|with family |with significant other |with DHHS worker |with case manager |by police|"][text memo="names" size="20"][select value=" for follow-up evaluation| for for evaluation and management of | due to reports of |"][checkbox value="depression|anxiety|cognitive impairment|impulsivity|mood lability|sleep disturbance"] [textarea memo="other" default="" rows="1"].[text memo="presenting problem" size="20"]. 


[checkbox memo="depression" name="dep" value=""][checkbox memo="anxiety" name="anx" value=""][checkbox memo="adhd" name="adhd" value=""][checkbox memo="sleep" name="sleep" value=""][checkbox memo="mood disorder" name="mood" value=""][conditional field="anxiety" condition="(anxiety).is('')"][/conditional][conditional field="dep" condition="(dep).is('')"]Depression is reported to be [select value="stable|better|somewhat better|somewhat worse|much worse|unchanged "][text]. [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea]. Reports depression to be present [select value="occasionally|almost never|about 50% of the time|most of the time on most days|almost always|"][text]. Depression is rated at [select value="1|2|3|4|5|6|7|8|9|10"]/10 with 10 being the worst. [textarea][/conditional][conditional field="anx" condition="(anx).is('')"]Anxiety is reported to be [select value="stable|better|somewhat better|somewhat worse|much worse|unchanged "][text]. [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|lack of response to medications|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea]. Reports anxiety to be present [select value="occasionally|mostly around situational stressors|almost never|about 50% of the time|most of the time on most days|almost always|"][text]. Anxiety is rated at [select value="1|2|3|4|5|6|7|8|9|10"]/10 with 10 being the worst. [textarea][/conditional][conditional field="adhd" condition="(adhd).is('')"]ADHD is reported to be [select value="stable|better|somewhat better|somewhat worse|much worse|unchanged "][text]. [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|lack of response to medications|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea]. Reports inattention to be present [select value="occasionally|mostly around situational stressors|almost never|about 50% of the time|most of the time on most days|almost always|"][text]. [textarea][/conditional][conditional field="sleep" condition="(sleep).is('')"]Sleep is reported to be [select value="stable|better|somewhat better|somewhat worse|much worse|unchanged "][text]. [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|lack of response to medications|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea]. Reports insomnia present [select value="occasionally|mostly around situational stressors|almost never|about 50% of the time|most of the time on most days|almost always|"][text]. [textarea][/conditional][conditional field="mood" condition="(mood).is('')"]Mood disorder is reported to be [select value="stable|better|somewhat better|somewhat worse|much worse|unchanged "][text]. [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|lack of response to medications|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea]. They report [checkbox value="depression|anxiety|irritability|mania|hypomania|impulsivity|emotional lability|"][text] to be present [select value="occasionally|mostly around situational stressors|almost never|about 50% of the time|most of the time on most days|almost always|"][text]. [textarea][/conditional]

ADHERENCE: The patient states they [select name="variable_12" value="are|are not"] taking all medications as prescribed. [textarea name="variable_1" default=""]

PSYCHIATRIC HISTORY AND SAFETY ASSESSMENT: 
Risk Assesment:
[select value="They are not currently receiving individual counseling/therapy|They are currently engaging in individual counseling with |"][textarea rows="1"].
[select value="They deny current suicidal ideation or thoughts of self harm|They report positive for |They deny suicidal ideation but state having thoughts of being better off dead"][textarea rows="1"].[select value="They deny having access to guns|They report positive for having guns in the home |"][textarea rows="1"]. [checkbox value=" Explained that we ask this question because guns in the home increase the risk of suicide, homicide and accidental death, Provided education about the importance of keeping guns locked and separated from ammunition. Explained that should this provider feel that patient is unsafe to self or others, provider and patient will work together to develop a safe place to keep weapons to decrease risk of impulsive suicide or homicide."]

MEDICAL HISTORY: 
Any changes in weight: [select name="variable_1" value="No|Yes"] 

PHYSICAL EXAMINATION

ROS: 
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 name="c" value="Steady gait while walking, normal strength bilaterally|"][conditional field="c" condition="(c).is('')"]
[checkbox value="steady gait while walking|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 "][/conditional][textarea memo="other" default="" rows="1"].
Medical conditions reported by the patient:[select name="variable_38" value="No change|"][textarea rows="1"] 

Current Medications:[select name="variable_39" value="No change|"][textarea rows="1"] 

Allergies: [select name="variable_37" value="No Change |"][textarea rows="1"] 

Female patients: 
Currently Pregnant or Family Planning: [select name="variable_13" value="N/A| Yes |No"]
Currently Breastfeeding: [select name="variable_14" value="N/A| Yes |No"]
Currently using some sort of Birth control method:[select name="variable_15" value="N/A| Yes |No"]

FAMILY HISTORY: 
Any changes to family medical or mental health status since last visit:[select name="variable_16" value="No| Yes"][textarea rows="1"]

SOCIAL/ LIFESTYLE: 
Any changes in living arrangements/ location: [select name="variable_17" value="No| Yes"][textarea rows="1"]
Any changes in Pertinent Relationships: [select name="variable_18" value="No| Yes"][textarea rows="1"]
Any changes in Employment: [select name="variable_19" value="No| Yes"][textarea rows="1"]
Any other new Acute Stressors: [select name="variable_21" value="No| Yes"][textarea rows="1"]

SUBSTANCE USE: 
Any changes to the client's substance use history since the last visit:[select name
Currently undergoing rehabilitation:[radio name="variable_22" value="No| Yes"][textarea rows="1"]
*Pt counseled on the importance of being substance-free* 

The patient [checkbox value=" presents with new symptoms of| presents with worsening symptoms of|denies new or worsening symptoms|reports improved symptoms of|reports"].[textarea memo="other" default="" rows="1"]

ASSESSMENT: 
[checkbox value="I reviewed thier PMP,|and found no abnormal results.|and found abnormal results "][textarea default="" rows="1"] The patient’s last refill of [textarea default="" rows="1"] was dispensed on [date name="variable_83" default=""]

Patient is currently displaying [select value="symptoms of|well managed|moderately managed|poorly managed"] [checkbox value="depression|anxiety|sleep disturbance|psychosis|substance use disorder|cognitive impairment|impulsivity|mood lability|alcohol dependence|opioid 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 substance use disorder|their trauma history|their depressive disorder|their anxiety disorder|their ADHD  disorder|their bipolar disorder|interpersonal/family conflict|the stressors of a rigorous substance use program|maladaptive behaviors|poor psychosocial support systems"][textarea memo="other" default="" rows="1"]. Patient would benefit from [checkbox value="continued psychopharmaceutical intervention|adjustments to current psychopharmaceutical intervention|Initiation of psychotherapy||continuation of current psychotherapy|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 psychotropic intervention|current apprehension to engage in Psychotherapy|current emotional distress due to unresolved trauma|limited social supports|dysfunctional interpersonal relationships|poor insight"][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|high intelligence"][textarea memo="strengths" rows="1"].

Patient [checkbox value="denies any intolerable side effects.|endorses medication side effects"][textarea memo="other" default="" rows="1"].[checkbox name="variable_1" value="No evidence of psychotic phenomenon;|Denies SI / HI / intent / plan |No acute medical concerns that would be contributing to current symptoms."][select value="They deny wanting medication changes at this time|They are open to considering further medication adjustments for the treatment of |The patient requests medication adjustmentsdue to|"][text].

Diagnosis
[checkbox name="dx" value="Major depressive disorder|recurrent|single episode|mild|moderate|severe|Bipolar II|Depression|Manic|hypomania|Mixed|without psychosis |with psychosis|Generalized anxiety disorder|Insomnia|PTSD |acute|chronic|ADHD |inattentive type|hyperactive type|mixed|Adjustment Disorder|with depressed mood|with anxiety|with depressed mood and anxiety"][textarea rows="1"].

PLAN: 
Pharmacological Interventions: [checkbox value="the following changes were made to client's treatment:|no changes were made to the client's treatment "][select name="prescription1" text memo="Rx #1" value="|Adderall XR 10 mg as needed per day|Adderall XR 15 mg as needed per day|Adderall XR 20 mg as needed per day|Adderall XR 25 mg as needed per day|Adderall XR 30 mg as needed per day|Adderall XR 5 mg as needed per day|Azstarys 26.1 mg as needed per day|Azstarys 39.2 mg as needed per day|Azstarys 52.3 mg as needed per day|Dyanavel XR 10 mg as needed per day|Dyanavel XR 15 mg as needed per day|Dyanavel XR 20 mg as needed per day|Intuniv 1mg daily|Intuniv 2mg daily|Intuniv 3mg daily|Intuniv 4mg daily|Kapvay 0.1mg daily|Kapvay 0.2mg daily|Prazosin 1mg at bedtime|Prazosin 2mg at bedtime|Prazosin 3mg at bedtime|Prazosin 4mg at bedtime|Qelbree 100mg daily|Qelbree 150mg daily|Qelbree 200mg daily||Qelbree 200mg daily for 14 days|Ritalin LA 10 mg as needed per day|Ritalin LA 20 mg as needed per day|Ritalin LA 30 mg as needed per day|Ritalin LA 40 mg as needed per day|Strattera 10mg daily|Strattera 18mg daily|Strattera 25mg daily|Strattera 25mg daily for 7 days then 40mg daily|Strattera 40mg daily|Strattera 60mg daily|Trazodone 25-50mg at bedtime as needed for insomnia|Trazodone 25mg at bedtime as needed for insomnia|Trazodone 50-100mg at bedtime as needed for insomnia|Trazodone 50mg at bedtime as needed for insomnia|Trintellix 10 mg daily|Vistaril 10 mg as needed for anxiety|Vistaril 10-20 mg as needed for anxiety|Vistaril 20 mg as needed for anxiety|Vistaril 25 mg as needed for anxiety|Vyvanse 10 mg as needed per day|Vyvanse 20 mg as needed per day|Vyvanse 30 mg as needed per day|Vyvanse 40 mg as needed per day|Vyvanse 50 mg as needed per day"]
[select name="prescription2" text memo="Rx #2" value="|Adderall XR 10 mg as needed per day|Adderall XR 15 mg as needed per day|Adderall XR 20 mg as needed per day|Adderall XR 25 mg as needed per day|Adderall XR 30 mg as needed per day|Adderall XR 5 mg as needed per day|Azstarys 26.1 mg as needed per day|Azstarys 39.2 mg as needed per day|Azstarys 52.3 mg as needed per day|Dyanavel XR 10 mg as needed per day|Dyanavel XR 15 mg as needed per day|Dyanavel XR 20 mg as needed per day|Intuniv 1mg daily|Intuniv 2mg daily|Intuniv 3mg daily|Intuniv 4mg daily|Kapvay 0.1mg daily|Kapvay 0.2mg daily|Prazosin 1mg at bedtime|Prazosin 2mg at bedtime|Prazosin 3mg at bedtime|Prazosin 4mg at bedtime|Qelbree 100mg daily|Qelbree 150mg daily|Qelbree 200mg daily||Qelbree 200mg daily for 14 days|Ritalin LA 10 mg as needed per day|Ritalin LA 20 mg as needed per day|Ritalin LA 30 mg as needed per day|Ritalin LA 40 mg as needed per day|Strattera 10mg daily|Strattera 18mg daily|Strattera 25mg daily|Strattera 25mg daily for 7 days then 40mg daily|Strattera 40mg daily|Strattera 60mg daily|Trazodone 25-50mg at bedtime as needed for insomnia|Trazodone 25mg at bedtime as needed for insomnia|Trazodone 50-100mg at bedtime as needed for insomnia|Trazodone 50mg at bedtime as needed for insomnia|Trintellix 10 mg daily|Vistaril 10 mg as needed for anxiety|Vistaril 10-20 mg as needed for anxiety|Vistaril 20 mg as needed for anxiety|Vistaril 25 mg as needed for anxiety|Vyvanse 10 mg as needed per day|Vyvanse 20 mg as needed per day|Vyvanse 30 mg as needed per day|Vyvanse 40 mg as needed per day|Vyvanse 50 mg as needed per day"]
[select name="prescription3" text memo="Rx #3" value="|Adderall XR 10 mg as needed per day|Adderall XR 15 mg as needed per day|Adderall XR 20 mg as needed per day|Adderall XR 25 mg as needed per day|Adderall XR 30 mg as needed per day|Adderall XR 5 mg as needed per day|Azstarys 26.1 mg as needed per day|Azstarys 39.2 mg as needed per day|Azstarys 52.3 mg as needed per day|Dyanavel XR 10 mg as needed per day|Dyanavel XR 15 mg as needed per day|Dyanavel XR 20 mg as needed per day|Intuniv 1mg daily|Intuniv 2mg daily|Intuniv 3mg daily|Intuniv 4mg daily|Kapvay 0.1mg daily|Kapvay 0.2mg daily|Prazosin 1mg at bedtime|Prazosin 2mg at bedtime|Prazosin 3mg at bedtime|Prazosin 4mg at bedtime|Qelbree 100mg daily|Qelbree 150mg daily|Qelbree 200mg daily||Qelbree 200mg daily for 14 days|Ritalin LA 10 mg as needed per day|Ritalin LA 20 mg as needed per day|Ritalin LA 30 mg as needed per day|Ritalin LA 40 mg as needed per day|Strattera 10mg daily|Strattera 18mg daily|Strattera 25mg daily|Strattera 25mg daily for 7 days then 40mg daily|Strattera 40mg daily|Strattera 60mg daily|Trazodone 25-50mg at bedtime as needed for insomnia|Trazodone 25mg at bedtime as needed for insomnia|Trazodone 50-100mg at bedtime as needed for insomnia|Trazodone 50mg at bedtime as needed for insomnia|Trintellix 10 mg daily|Vistaril 10 mg as needed for anxiety|Vistaril 10-20 mg as needed for anxiety|Vistaril 20 mg as needed for anxiety|Vistaril 25 mg as needed for anxiety|Vyvanse 10 mg as needed per day|Vyvanse 20 mg as needed per day|Vyvanse 30 mg as needed per day|Vyvanse 40 mg as needed per day|Vyvanse 50 mg as needed per day"][text name   memo="Rx other" ="variable_1" default=""] 

Non-Pharmacological Interventions: 
1. Start/continue eating a balanced diet
2. Start/continue exercising at least three times a week
3. Start/continue psychotherapy

The patient verbalizes understanding, agrees to this treatment plan, and agrees to coordinate care as needed.

Follow-up in 
[checkbox name="variable_1" value="2 weeks|4 weeks"][text name="variable_1" default=""]

Informed Consent:[var name="name"] consents to treatment and consultation

Psychoeducation is provided regarding the benefits, risks, side effects, and alternatives to the patient’s medication treatment plan. The provider and patient discussed the danger of misuse of stimulant medications, and the patient agreed to take medication only for themselves. The patient is to contact our office with any questions, concerns, adverse side effects, or changes in mental health status. The patient is advised to call 911, 988, or go to the nearest emergency room if the patient experiences a medical or mental health emergency, including but not limited to suicidal or homicidal ideation or plans. The patient is advised against using alcohol and/or illicit substances while on psychotropic medication due to the risk of negative interactions and is aware doing so will be at his/her own risk. The patient is recommended to discuss this diagnosis and treatment plan with their PCP, as we don't want to have overriding and/or conflicting plans. The patient is encouraged to follow up with PCP for routine health and lab monitoring and maintenance. 

The patient’s preferred pharmacy was verified and updated in the chart. ID verification verified

Keife Earley, DNP, PMHNP-BC

Please note that this message was created using voice dictation. Despite best efforts to ensure accuracy and completeness, there is a possibility of errors or omissions.

central time

This Patient’s Last Video Visit with a Provider was on

Patient name is a years-old, race,gender

History of Presenting Illness:
name that names
other.presenting problem.


depression anxiety adhd sleep mood disorder

ADHERENCE: The patient states they taking all medications as prescribed.


PSYCHIATRIC HISTORY AND SAFETY ASSESSMENT:
Risk Assesment:
.
.
.

MEDICAL HISTORY:
Any changes in weight:

PHYSICAL EXAMINATION

ROS:
Appearance: ,
other.

Gait and Station / Muscle Strength and Tone:
other.
Medical conditions reported by the patient:


Current Medications:


Allergies:


Female patients:
Currently Pregnant or Family Planning:
Currently Breastfeeding:
Currently using some sort of Birth control method:

FAMILY HISTORY:
Any changes to family medical or mental health status since last visit:


SOCIAL/ LIFESTYLE:
Any changes in living arrangements/ location:

Any changes in Pertinent Relationships:

Any changes in Employment:

Any other new Acute Stressors:


SUBSTANCE USE:
Any changes to the client's substance use history since the last visit:

*Pt counseled on the importance of being substance-free*

The patient .
other

ASSESSMENT:
The patient’s last refill of
was dispensed on

Patient is currently displaying
other which is
other. Patient would benefit from
other. Prognosis is considering the patient medication/therapy to address
target of treatment .
barriers.
strengths.

Patient
other. .

Diagnosis
.

PLAN:
Pharmacological Interventions: Rx #1
Rx #2
Rx #3Rx other

Non-Pharmacological Interventions:
1. Start/continue eating a balanced diet
2. Start/continue exercising at least three times a week
3. Start/continue psychotherapy

The patient verbalizes understanding, agrees to this treatment plan, and agrees to coordinate care as needed.

Follow-up in


Informed Consent:name consents to treatment and consultation

Psychoeducation is provided regarding the benefits, risks, side effects, and alternatives to the patient’s medication treatment plan. The provider and patient discussed the danger of misuse of stimulant medications, and the patient agreed to take medication only for themselves. The patient is to contact our office with any questions, concerns, adverse side effects, or changes in mental health status. The patient is advised to call 911, 988, or go to the nearest emergency room if the patient experiences a medical or mental health emergency, including but not limited to suicidal or homicidal ideation or plans. The patient is advised against using alcohol and/or illicit substances while on psychotropic medication due to the risk of negative interactions and is aware doing so will be at his/her own risk. The patient is recommended to discuss this diagnosis and treatment plan with their PCP, as we don't want to have overriding and/or conflicting plans. The patient is encouraged to follow up with PCP for routine health and lab monitoring and maintenance.

The patient’s preferred pharmacy was verified and updated in the chart. ID verification verified

Keife Earley, DNP, PMHNP-BC

Please note that this message was created using voice dictation. Despite best efforts to ensure accuracy and completeness, there is a possibility of errors or omissions.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.61, 146 form elements, 435 boilerplate words, 17 text boxes, 37 text areas, 3 dates, 29 checkboxes, 51 drop downs, 2 variables, 7 conditionals, 257 total clicks
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