Psychiatry
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HISTORY OF PRESENTING PROBLEM

*Chief Complaint*
Date of Service:[date default="today"] [text size="6"]
Patient is see in this intake for [checkbox value="depression|anxiety|psychosis|substance abuse|cognitive impairment|impulsivity|mood lability|sleep disturbance|alcohol dependence|opiate dependence|autism spectrum disorder"] [textarea memo="other" default="" rows="1"]
[textarea memo="quotes" default="" rows="1"]

*Interval History*
Patient remains [comment memo="SYMPTOM"][checkbox value="depressed|anxious|aggressive|impulsive|inattentive|irritable|withdrawn|unable to sleep|delusional|auditory hallucinations|visual hallucinations"][textarea memo="other" default="" rows="1"].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"]

Scales and Screening:
PHQ-9: [select value="unable to assess|declined|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
GAD-7: [select value="unable to assess|declined|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]

*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|heartburn|denied"][textarea memo="other" default="" rows="1"]
All other systems negative

*Past/Family/Social History*
[textarea rows="3"]

PHYSICAL HEALTH HISTORY
Vital Signs:
Weight- [text size="8"]
Height- [text size="8"]
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"]


Time spent in psychotherapy:[checkbox value="38-52 min"][comment memo="45 min 90836"][checkbox value="53-67 min"][comment memo="60 min 90838"]
Focus of psychotherapy:[checkbox value="interpersonal conflict|emotional experience related to diagnosis|identification of coping mechanisms|grief counseling"][textarea memo="other" default="" rows="1"]
Modality:[checkbox value="insight oriented|supportive|behavioral modification"]

Medication List:
[textarea rows="3"]

Diagnosis:[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="2"]

Allergies:
[textarea rows="3"]

Significant Medical Issues:
[textarea rows="3"]

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 cancer diagnosis|their cancer treatment|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="continued psychopharmaceutical intervention|adjustments to current psychopharmaceutical intervention|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 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="2"]


GOALS
[checkbox value="-Patient will report score on PHQ-9 of 8 or less within 3 months: Initiated "][textarea rows="1"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][checkbox value="
-Patient will report score on GAD-7 of 8 or less within 3 months: Initiated "][textarea rows="1"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][checkbox value="
-Patient will reduce nicotine intake by 50% within one month: Initiated "][textarea rows="1"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][checkbox value="
-Patient will experience 6+ hours of uninterrupted sleep per night within 3 months: Initiated "][textarea rows="1"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][checkbox value="
-Patient will report impact of cognitive impairment as mild/resolved within 3 months: Initiated "][textarea rows="1"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"]
HISTORY OF PRESENTING PROBLEM

*Chief Complaint*
Date of Service:
Patient is see in this intake for other
quotes

*Interval History*
Patient remains SYMPTOM other.
Which is described asSEVERITY other
The patient notices that it is sometimes improved by Modifying factors other

Scales and Screening:
PHQ-9:
GAD-7:

*Review of Systems* Include for 99213 thru 99215
The patient identifies the following symptoms: Pertinent System other
Other systems:
Neurological - other
GI - other
All other systems negative

*Past/Family/Social History*


PHYSICAL HEALTH HISTORY
Vital Signs:
Weight-
Height-
Appearance: , other
Gait and Station / Muscle Strength and Tone: other
Mood and Affect:
Mood- other
Affect- other
Speech: other
Thought process: other
Associations: other
Thought Content: other
Orientation: other
Attention and Concentration: other
Memory: other
Language: other
Judgment and Insight:
Judgment- other
Insight- other
Fund of Knowledge: Based on the answers to interview questions, patient's intelligence is judged to be other


Time spent in psychotherapy: 45 min 90836 60 min 90838
Focus of psychotherapy: other
Modality:

Medication List:


Diagnosis:


Allergies:


Significant Medical Issues:


ASSESSMENT
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.


GOALS

Result - Copy and paste this output: