Adult New intial 6/13

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

[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="relationship" memo="Martial Status" value="|single|married|divorced|partnered"][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"] who presents for an initial psychiatric evaluation [select value="via telehealth| in-person office "][select value="alone|with family |with significant other |with DHHS worker |with case manager |by police|"][text memo="names" size="20"][select value=" for evaluation and management of | due to reports of |management of"][checkbox name="concerns" value="depression|anxiety|cognitive impairment|impulsivity|mood lability|sleep disturbance|treatment managment"] [textarea memo="other" default="" rows="1"].[text memo="presenting problem" size="20"]. [select value="The patient reports |The family reports |The Guardian reports |The case manager reports |Electronic records indicate |Police report indicates |"][select value="a past history of|no history of mental health concerns until |no history of mental health concerns|"][textarea name="hx" memo="Mental health history" rows="2"]

[checkbox name="depression" memo="depression" value=""][checkbox name="anxiety" memo="anxiety" value=""][checkbox name="sleep" memo="sleep" value=""][checkbox name="mood" memo="mood" value=""][checkbox name="ptsd" memo="ptsd" value=""][checkbox name="adhd" memo="adhd" value=""][checkbox name="autism" memo="autism" value=""][conditional field="depression" condition="(depression).is('')"]
[var name="name"]'s presents with symptoms [checkbox value="little interest or pleasure in doing things|hopelessness|helplessness|sleeping too much|difficulty getting to sleep|difficulty staying asleep|feeling tired or having little energy|poor appetite|overeating|feelings of inadequacy|irritability|poor concentration|psychomotor retardation|psychomotor agitation|suicidal ideation"]. [select value="Depressive symptoms are present most of the day, nearly every day|Depressive symptoms are mostly present |"][text size="20"][select value=", are exacerbated by |"][text size="20][select value=", are improved by |"][text size="20]. [select value="Depressive symptoms impact|"][select value=" social/work functioning by | "][textarea rows="1"].They rate their level of depression as [select value="1|2|3|4|5|6|7|8|9|10"]/10 , with 10 being the most severe..[textarea memo="Additional Depression information" rows="5"][/conditional]

[conditional field="anxiety" condition="(anxiety).is('')"]
[var name="name"]'s presents with symptoms [checkbox value="feeling nervous or on edge|worry|difficulty relaxing|feeling restless|difficulty getting to sleep|difficulty staying asleep|irritability|poor appetite|overeating"][text size="20]. [select value="Anxiety is present |"][select value="in the context of multiple different situations/events such as |primarily in social situations such as | "][textarea rows="1"]. [select value="Anxiety usually last for approximately |Anxiety is present most of the time on most days"][text size="20"][select value=", is brought on by |"][text size="20][select value=", is relieved by |"][text size="20]. Client rates anxiety [select value="1|2|3|4|5|6|7|8|9|10"]/10, with 10 being the most severe. [textarea memo="Additional Anxiety information" rows="5"][/conditional][conditional field="mood" condition="(mood).is('')"]

[select value=" Mood instability has been an issue since |"][text size="20"]. [select value="Disordered mood can present as |"][checkbox value="euphoria|excessive energy|excessive self-confidence|insomnia|irritability|agitation|racing thoughts|impulsive behavior|risk taking behavior|paranoia|delusions of grandeur|auditory hallucinations|visual hallucinations|depression|apathy|hopelessness|helplessness|suicidal thoughts|no motivation|hypersomnia"]. [select value="Mood lability is exacerbated by |There are no identified precipitating factors to mood lability|"][textarea rows="1"]. [textarea memo="additional information of mood lability" rows="4"][/conditional][conditional field="autism" condition="(autism).is('')"]

[select value="Per patient,|Per family,|Per record,|"][text size="20"][select value=" they have been | patient has been |"][select value="diagnosed|undiagnosed|"][text size="20"][select value=" autism spectrum disorder "][textarea memo="details of diagnosis/symptom timeframe" rows="4"]. [var name="name"]'s symptoms present as persistent difficulty, in multiple contexts, with social communication and interaction including: [checkbox value="abnormal or failed back and forth conversation|failure to initiate or respond to social interactions|reduced sharing of interests/emotions|limited emotional affect|limited/incongruent nonverbal communication|difficulty with developing/maintaining/understanding relationships|difficulty sharing imaginative play|limited or absent interest in peers"]. They have demonstrated restricted/repetitive patterns of behavior, interests, or activities including: [checkbox value="repetitive motor movements|repetitive speech|infexible adherence to routines|ritualized patterns of verbal or nonverbal behavior|significant difficulty with transitions|rigid thinking patterns|highly restricted and fixated interests|hyper-reactivity to sensory input|hyporeactivity to some sensory input"]. Presentation is [select value="without|with"] intellectual impairment, and [select value="without|with"] language impairment. [textarea rows="4"][/conditional][conditional field="adhd" condition="(adhd).is('')"]

[var name="name"] has a pattern of [checkbox name=addtype value="inattention and hyperactivity/impulsivity|inattention|hyperactivity/impulsivity"] that interferes with functioning. [/conditional][conditional field="addtype" condition="(addtype).is('inattention and hyperactivity/impulsivity')||(addtype).is('inattention')"] Inattention manifests as [checkbox memo="At least 6 for ADHD" value="poor attention to details or careless mistakes in work or activities|difficulty sustaining attention|not seeming to listen when spoken to directly|not following through on instructions or failing to finish tasks|having difficulty organizing tasks and activities|avoiding tasks that require sustained mental effort|frequently losing things necessary for tasks|often easily distracted by extraneous stimuli|forgetfulness in daily activities"].[/conditional] [conditional field="addtype" condition="(addtype).is('inattention and hyperactivity/impulsivity')||(addtype).is('hyperactivity/impulsivity')"] [var name="name"]'s hyperactivity/impulsivity presents as [checkbox memo="six or more for ADHD" value="frequent fidgeting or squirming|often leaving seat when remaining seated is expected|frequently restless|difficulty engaging in leisure activities quietly|often seeming to be on the go or difficult to keep up with|excessive talking|blurting out answers before a question has been completed|difficulty waiting for their turn|interrupting or intruding on others"].[/conditional][conditional field="adhd" condition="(adhd).is('')"] These symptoms have been present since [text memo="before 12yo" size="20"], and are recognized in multiple settings including [text memo="2 or more" size="20"]. [textarea rows="3"]

[/conditional][conditional field="sleep" condition="(sleep).is('')"]
Sleep is reported to be generally [select name="sleepq" value="poor |fair |good.|erratic |inconsistent |excessive|"][select value="with difficulty initiating sleep and staying asleep due to |with difficulty initiating sleep due to |with difficulty maintaining sleep due to |"][textarea rows="2"]. They estimate getting approximately [text size="4"] hours of [select value="broken |solid |"]sleep per night. [select value="Disturbed sleep has been an issue for |Disturbed sleep is a new issue within the last |"][textarea rows="1"]. [select value="There has been no workup for Sleep Apnea|There was a past workup for sleep apnea which indicated |"][textarea rows="1"]. [select value="Current attempts at improving sleep include |The patient is currently attempting no interventions to improve sleep|Current quality of sleep is dependent on |"][textarea rows="2"]. [select value="Past unsuccessful attempts at improving sleep include |There have been no past attempts at improving sleep|"][textarea rows="2"].[/conditional]

SUBSTANCE USE
[select value="They report consuming caffeine:|They deny any caffeine consumtion|"] [textarea rows="1"].[select value="They deny any nicotine use|They use nicotine use |They report a past history of nicotine but quit approximately"][textarea rows="1"]. [select value="They deny any alcohol use|They report positive for alcohol use consuming approximately |They report a history abuse quitting approximately|"][textarea rows="1"]. [select value="They deny a history of recreational substance use|They report utilizing cannabis approximately |They have a history of opiate use disorder |They report utilizing opiates recreationally in the form of |Substance use history was not covered due to symptomatic presentation|"][textarea rows="1"]. [select value="They deny being currently in a substance abuse and/or MAT program |They are currently in a substance abuse and/or MAT program|"][textarea rows="1"].

PSYCHIATRIC HISTORY:
Current Medications: [text name="Cmeds" textarea rows="1"] [select value="Previous psychiatric medication trials include but may not be limited to: |The patient has no history of taking psychiatric medications|We were unable to cover previous psychiatric medication trials due to symptomatic presentation|The patient is unable to recall past psychiatric medication trials|"][textarea rows="1"].[select value="Client denies a history of psychiatric hospitalizations|They have been psychiatrically hospitalized |"][textarea rows="1"]. [select value="Previous psychiatric/counseling services includes |They have no history of psychiatric/counseling|History of psychotherapy/counseling was not addressed due to symptomatic presentation|"][textarea rows="1"]. [select value="They deny history of diagnosis/treatment for an eating disorder|They report positive for a history of diagnosis/treatment for an eating disorder including |Unable to assess for history of diagnosis/treatment of an eating disorder due to symptomatic presentation|History of diagnosis/treatment of an eating disorder was not assessed in this encounter|"][textarea rows="1"]. [select value="They deny a history of thoughts of self-harm|They deny suicidal ideation but state having thoughts of being better off dead|History of thoughts of self harm include|"][textarea rows="1"]. [select value="They have no history of attempting to hurt themself|History of self-harm includes |Unable to obtain history of self-harm due to symptomatic presentation"][textarea rows="1"]. [select value="They have no history of head injuries or traumatic brain injuries|They have a past history of traumatic brain injuries resulting from |They have an underlying cognitive impairment from |"][textarea rows="1"]. [select value="There is no history of trauma|They report having a history of trauma but did not want to elaborate|They report past traumatic experiences to include |Trauma history was not covered due to symptomatic presentation|"][textarea rows="1"].

SOCIAL HISTORY:
[var name="name"] currently lives with [checkbox value="no one / alone|significant other|extended family|children|friends|roommates"][textarea rows="1"].The patient reports their housing is stable and currently feels [checkbox value="safe|unsafe"] in their home environment. [var name="name"]Identifies [checkbox value="having no one|significant other|extended family|children|friends|church members"][textarea rows="1"] as their social-support network. They have [select value="0|1|2|3|4|5|6|7|"][textarea rows="1"] children. Their level of education is [select value="highschool|an associate degree in |an undergraduate degree in |a graduate degree in |some highschool|some college|currently in grade school|currently in highschool|currently in college studying |currently in graduate school studying |"][textarea rows="1"]. They are [select value="currently employed |currently unemployed |currently on disability due to their mental health condition|currently at full-time student |currently on disability due to their medical condition|currently retired from |"][textarea rows="1"]. Financially they [select value="have no immediate concerns|are burdened by healthcare costs|have concerns related to supporting their family|"][textarea rows="1"]. Their source of income is primarily [select value="current employment|disability|social security|unemployment|family support|retirement|"][textarea rows="1"]. They have [select value="no current housing concerns|a currently unstable housing situation related to |"][textarea rows="1"]. [select name="spirituality" value="Spirituality was not addressed this visit|Spirituality is identified as |"][conditional field="spirituality" condition="(spirituality).is('Spirituality is identified as ')"][select value="Christian|Catholic|Muslim|Jewish|Spiritual but not practicing|Athiest|Agnostic|"][textarea rows="1"][/conditional]. [select value="Cultural considerations important to care include: |"][textarea rows="1"]. Sexual orientation [select name="sexuality" value="is identified as |was not addressed this visit|"][conditional field="sexuality" condition="(sexuality).is('is identified as ')"][select value="straight|gay|lesbian|bisexual|pansexual|asexual|"][textarea rows="1"][/conditional]. [select value="They have no military history|Military history includes |Military history was not addressed this visit|"][textarea rows="1"]. [select value="They have no current legal concerns|Legal concerns include |Legal concerns were not addressed due to symptomatic presentation"][textarea rows="1"].

FAMILY PSYCHIATRIC HISTORY:
[select value="They deny knowledge of a family history of mental illness|Family history of mental health problems is positive for |Unable to cover family history of psychiatric issues due to symptomatic presentation"][textarea rows="1"]. [select value="There is no known history of suicides or self-harm in the patient's family|Family history of suicides/self-harm includes |Unable to cover family history of suicides/self-harm due to symptomatic presentation|"][textarea rows="2"]. [select value="There is no known family history of substance use issues|Family history of substance use is positive for |Unable to cover family history of substance use issues due to symptomatic presentation|"][textarea rows="1"].

Fund of Knowledge: Based on the answers to interview questions, [var name="name"]'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"][conditional field="b" condition="(b).is(' with psychotherapy')"].

TREATMENT AND PRESCRIPTIONS
[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 200 mg for 7 days then 400 mg 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="Rxmisc" memo="Rx other" ="variable_1" default=""]

[var name="name"] is a [var name="age"] year old [var name="relationship"] [var name="race"] [var name="gender"] with past psychiatric history of [var name="hx"], presenting with concerns for [var name="concerns"]. Based on [var name="name"]’s interview, review of symptoms, screening measures, and this provider’s thorough assessment, the patient has met the DSM-V diagnostic criteria for [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"][text name="Dxmisc" memo="Dx other" ="variable_1" default=""]

[var name="name"] reports the symptoms are causing maladaptive functioning and impairment in their personal, occupational, and social settings. [var name="name"] has been unable to alleviate these symptoms on their own through non-pharmacological interventions and are in need of medication management which will require continued treatment.[var name="name"] currently denies suicidal or homicidal ideation.

Medication choices were discussed and the provider and patient agreed that [var name="prescription1"]  [var name="prescription2"]  [var name="prescription3"] [var name="Rxmisc"] will be beneficial to manage [var name="name"]'s symptoms.[var name="name"] verbalized their consent and willingness to participate in the following proposed treatment plan.

We reviewed therapeutic duration of medication, dosing strategies, side effects, and assessing improvements in symptoms.

[var name="name"] would benefit from [checkbox value="initiation of psychopharmaceutical intervention|continued psychopharmaceutical intervention|adjustments to current psychopharmaceutical intervention"] [textarea rows=""]

Pharmacological Interventions:
Start: [var name="prescription1"][var name="prescription2"] [var name="prescription3"] [var name="Rxmisc"]
[select value="|N/A |Discontinue:|Continue:"] [var name="Cmeds"]


Non-Pharmacological Interventions:
[var name="name"] would benefit from
1. Eating a balanced diet
2. Exercising at least three times a week
3. Psychotherapy
4. Increasing personal time and self-care
[checkbox value="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 rows=""]

*Please be aware that this note was generated using voice dictation. Although we have made every effort to ensure the accuracy and completeness of the note, errors and omissions may occur.

[var name="name"],

It was wonderful meeting with you!

This is our current treatment plan, as discussed during your visit:

DIAGNOSIS: [var name="dx"][var name="Dxmisc"]
PLAN: [var name="prescription1"] [var name="prescription2"] [var name="prescription3"] [var name="Rxmisc"]
[select value="|N/A|Discontinue:|Continue:"] [var name="Cmeds"]

Non-Pharmacological Interventions:
1. Eating a balanced diet
2. Exercising at least three times a week
3. Psychotherapy
4. Increasing personal time and self-care
[checkbox value="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 rows=""]

Your prescription has been sent to the pharmacy of your choice:

FOLLOW-UP RECOMMENDATIONS:
Asynchronously, we can communicate via the "Consultation" tab in your Done patient portal. Feel free to message me anytime, especially if you suffer any side effects, the treatment is not working well or have any questions. However, please allow up to 72 hours for a response. If you're experiencing an emergency, please seek urgent care or call 911.

You can follow up via a scheduled video follow-up appointment.

To closely monitor your progress as well as continue your ongoing medication management. I recommend you follow up in 4 weeks. I must see you via video appointment every six months AT MINIMUM. As my schedule can sometimes be full up to several weeks in advance, it is strongly encouraged to attempt to schedule your follow-up appointment at least two weeks before the required deadline.

MEDICATION REFILLS:
You can request refills from within your Done patient portal. You should be able to request a new refill five before you're due for more, as long as you are not overdue for your six-month check-in. If treatment is not going well and you feel we may need to adjust your plan, please message us or schedule a follow-up appointment as needed. https://support.donefirst.com.

--------
SIDE EFFECTS: Stimulant medication may raise your blood pressure. Check your blood pressure regularly and tell your provider if the results are high. Loss of appetite, weight loss, dry mouth, stomach upset/pain, nausea/vomiting, dizziness, headache, diarrhea, fever, nervousness, change in libido, and trouble sleeping may occur. Tell your provider right away if you have any serious side effects, including signs of blood flow problems in the fingers or toes (such as coldness, numbness, pain, or skin color changes,) uncontrolled movements, continuous chewing movements/teeth grinding, or any mood/behavior changes (such as agitation, aggression, mood swings, depression or abnormal thoughts.)

CAUTION: Get medical help right away if you have any very serious side effects, including shortness of breath, chest/jaw/left arm pain, fainting, severe headache, fast/pounding/irregular heartbeat, seizures, weakness on one side of the body, trouble speaking, confusion, swollen ankles/feet, extreme tiredness, blurred vision, thoughts of suicide. This is not a complete list of possible side effects. Contact your provider or pharmacist if you notice other effects not listed above.
Misuse or abuse of stimulants may cause serious (possibly fatal) heart and blood pressure problems or risk of tolerance, dependence, and addiction. Use only as directed. We do not provide emergency services; if you have a psychiatric or emergency crisis, please call 911 or go to the nearest Emergency room.

National Suicide Prevention Lifeline URL: https://988lifeline.org/
National Suicide Prevention Lifeline Phone: 1-800-273-8255

For more questions, concerns, or side effects, please visit our website: https://www.donefirst.com.

Keife Earley DNP, PMHNP-BC

*Please be aware that this note was generated using voice dictation. Although we have made every effort to ensure the accuracy and completeness of the message, errors and omissions may occur.*
central time

Patient nameis a years-old, race,Martial Statusgender

History of Presenting Illness:
name who presents for an initial psychiatric evaluation names
other.presenting problem.
Mental health history

depression anxiety sleep mood ptsd adhd autism



SUBSTANCE USE
.
.
.
.
.

PSYCHIATRIC HISTORY:
Current Medications:
.
.
.
.
.
.
.
.

SOCIAL HISTORY:
name currently lives with
.The patient reports their housing is stable and currently feels in their home environment. nameIdentifies
as their social-support network. They have
children. Their level of education is
. They are
. Financially they
. Their source of income is primarily
. They have
. .
. Sexual orientation .
.
.

FAMILY PSYCHIATRIC HISTORY:
.
.
.

Fund of Knowledge: Based on the answers to interview questions, name's intelligence is judged to be
other.

TREATMENT AND PRESCRIPTIONS
Rx #1
Rx #2
Rx #3
Rx other

name is a age year old relationship race gender with past psychiatric history of hx, presenting with concerns for concerns. Based on name’s interview, review of symptoms, screening measures, and this provider’s thorough assessment, the patient has met the DSM-V diagnostic criteria for Dx other

name reports the symptoms are causing maladaptive functioning and impairment in their personal, occupational, and social settings. name has been unable to alleviate these symptoms on their own through non-pharmacological interventions and are in need of medication management which will require continued treatment.name currently denies suicidal or homicidal ideation.

Medication choices were discussed and the provider and patient agreed that prescription1 prescription2 prescription3 Rxmisc will be beneficial to manage name's symptoms.name verbalized their consent and willingness to participate in the following proposed treatment plan.

We reviewed therapeutic duration of medication, dosing strategies, side effects, and assessing improvements in symptoms.

name would benefit from


Pharmacological Interventions:
Start: prescription1prescription2 prescription3 Rxmisc
Cmeds


Non-Pharmacological Interventions:
name would benefit from
1. Eating a balanced diet
2. Exercising at least three times a week
3. Psychotherapy
4. Increasing personal time and self-care



*Please be aware that this note was generated using voice dictation. Although we have made every effort to ensure the accuracy and completeness of the note, errors and omissions may occur.

name,

It was wonderful meeting with you!

This is our current treatment plan, as discussed during your visit:

DIAGNOSIS: dxDxmisc
PLAN: prescription1 prescription2 prescription3 Rxmisc
Cmeds

Non-Pharmacological Interventions:
1. Eating a balanced diet
2. Exercising at least three times a week
3. Psychotherapy
4. Increasing personal time and self-care





Your prescription has been sent to the pharmacy of your choice:

FOLLOW-UP RECOMMENDATIONS:
Asynchronously, we can communicate via the "Consultation" tab in your Done patient portal. Feel free to message me anytime, especially if you suffer any side effects, the treatment is not working well or have any questions. However, please allow up to 72 hours for a response. If you're experiencing an emergency, please seek urgent care or call 911.

You can follow up via a scheduled video follow-up appointment.

To closely monitor your progress as well as continue your ongoing medication management. I recommend you follow up in 4 weeks. I must see you via video appointment every six months AT MINIMUM. As my schedule can sometimes be full up to several weeks in advance, it is strongly encouraged to attempt to schedule your follow-up appointment at least two weeks before the required deadline.

MEDICATION REFILLS:
You can request refills from within your Done patient portal. You should be able to request a new refill five before you're due for more, as long as you are not overdue for your six-month check-in. If treatment is not going well and you feel we may need to adjust your plan, please message us or schedule a follow-up appointment as needed. https://support.donefirst.com.

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SIDE EFFECTS: Stimulant medication may raise your blood pressure. Check your blood pressure regularly and tell your provider if the results are high. Loss of appetite, weight loss, dry mouth, stomach upset/pain, nausea/vomiting, dizziness, headache, diarrhea, fever, nervousness, change in libido, and trouble sleeping may occur. Tell your provider right away if you have any serious side effects, including signs of blood flow problems in the fingers or toes (such as coldness, numbness, pain, or skin color changes,) uncontrolled movements, continuous chewing movements/teeth grinding, or any mood/behavior changes (such as agitation, aggression, mood swings, depression or abnormal thoughts.)

CAUTION: Get medical help right away if you have any very serious side effects, including shortness of breath, chest/jaw/left arm pain, fainting, severe headache, fast/pounding/irregular heartbeat, seizures, weakness on one side of the body, trouble speaking, confusion, swollen ankles/feet, extreme tiredness, blurred vision, thoughts of suicide. This is not a complete list of possible side effects. Contact your provider or pharmacist if you notice other effects not listed above.
Misuse or abuse of stimulants may cause serious (possibly fatal) heart and blood pressure problems or risk of tolerance, dependence, and addiction. Use only as directed. We do not provide emergency services; if you have a psychiatric or emergency crisis, please call 911 or go to the nearest Emergency room.

National Suicide Prevention Lifeline URL: https://988lifeline.org/
National Suicide Prevention Lifeline Phone: 1-800-273-8255

For more questions, concerns, or side effects, please visit our website: https://www.donefirst.com.

Keife Earley DNP, PMHNP-BC

*Please be aware that this note was generated using voice dictation. Although we have made every effort to ensure the accuracy and completeness of the message, errors and omissions may occur.*

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Sandbox Metrics: Structured Data Index 0.59, 217 form elements, 820 boilerplate words, 19 text boxes, 49 text areas, 1 dates, 23 checkboxes, 72 drop downs, 41 variables, 12 conditionals, 294 total clicks
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