CODAC iNTAKE

Psychiatry & Psychology
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[frontload soapnote="shorthand/shorthand-base/"]
CC:[text name="CC" default="Substance Use Disorder Intake" size=23]
S:[textarea name="Subjective" default="History:****** Substance of Choice:****** Last use, Route, Duration, Any period of abstence?******"]
Any history of OD:
[select name="OD" value="Denies|Yes"] Any use of Narcan? [select name="Narcan" value="Denies|Yes"] Any history of detox : [select name="Detox" value="Denies|Yes"]
Other substance use:
Caffeine: [text name="Caffeine" default="Denies"];Nicotine: [text name="Nicotine" default="Number of Cigarettes:" size=23]; Alcohol: [text name="Alcohol" default="Number of standard drinks:" size=30]; Marijuana: [text name="MJ" default="Amount spent on marijuana products" size=40]; Stimulants: [text name="stim" default="amount/days used" size=23]; Other
[text name="othersub" default="N/A"]

Medical dx/ PMH:
[textarea name="MedHx" default="none"]
Current Medications:
[textarea name="Meds" default="none"]
Allergies:
[textarea name="Allergies" default="NKDA"]
Surgery/ hospitalizations:
[textarea name="SurgHx" default="none"]
Family history:
[textarea name="FamHx" default="none"]
Psychiatric diagnoses:
[textarea name="MedHx" default="Psych medications? Hx of inpatient care? Prior suicide attempts?"]

Social History:
Gender/ preferred pronouns: [text name="Pronouns" default="he/him"], Living situation: [text name="livingSituation" default="housed"] Income/Employment: [text name="Income" default="$X"], Transportation: [text name="transport" default="private vehicle"], Relationships: [text name="relationships" default="Significant other"], Religious/ Spiritual beliefs: [text name="Religion" default="Christion"], Legal history/issues: [text name="Legal" default="Denies"], History of trauma, abuse, neglect/ ACES: [text name="Trauma" default="Denies"], Military history: [text name="Military" default="No history of military service"]

ROS:
[textarea name="ROS" default="%ros"]

O: Neuro- AAOX3 HEENT- eyes no erythema or icterus Oropharynx – clear Neck- supple no adenopathy CV- RRR no murmurs Chest- CTA Abd- soft, NT, ND no HSM Skin- warm dry, no lesion, no track marks Ext- no edema
MSE:
[textarea name="MSE" default="%mseall"]


[comment memo="#OUD, severe, FYL, Heroin. no IVDU hx
-reviewed risks, benefits of methadone use incl risk of OD/death if mixed with etoh and/ or benzos, taking with other opioids, or returning to opioid use after stopping methadone
-pt expressed understanding and desire to re-start tx with methadone. prev took x ~ 1 yr at CMS and maintained sobriety during that time and ~1.5 yr post stopping. was on 68-72 mg/d
-start 30 mg today. Increase dose by 10 mg QD up to 60 mg daily. then may increase by 5 mg up to 70 mg/d. consider further increase if persistent w/d, cravings
-narcan education and kit given
-f/u in 1 M or sooner prn"]

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This is the first Shorthand library. When you enter the letters of a Shorthand code, they are expanded after you click ‘Calculate Result’. It currently includes ‘%ros’ (review of systems), ‘%exam’ (exam), ‘%edu’ (education), and ‘%mseall’ (a condensed normal mental status exam). To use this, you can either copy it to your own SOAPnote or you can use the ‘frontload’ feature. To frontload this to your own templates, put [frontload soapnote="shorthand/shorthand-base/"] at the very beginning of your note.
CC:
S:
Any history of OD:
Any use of Narcan? Any history of detox :
Other substance use:
Caffeine: ;Nicotine: ; Alcohol: ; Marijuana: ; Stimulants: ; Other


Medical dx/ PMH:

Current Medications:

Allergies:

Surgery/ hospitalizations:

Family history:

Psychiatric diagnoses:


Social History:
Gender/ preferred pronouns: , Living situation: Income/Employment: , Transportation: , Relationships: , Religious/ Spiritual beliefs: , Legal history/issues: , History of trauma, abuse, neglect/ ACES: , Military history:

ROS:


O: Neuro- AAOX3 HEENT- eyes no erythema or icterus Oropharynx – clear Neck- supple no adenopathy CV- RRR no murmurs Chest- CTA Abd- soft, NT, ND no HSM Skin- warm dry, no lesion, no track marks Ext- no edema
MSE:



#OUD, severe, FYL, Heroin. no IVDU hx
-reviewed risks, benefits of methadone use incl risk of OD/death if mixed with etoh and/ or benzos, taking with other opioids, or returning to opioid use after stopping methadone
-pt expressed understanding and desire to re-start tx with methadone. prev took x ~ 1 yr at CMS and maintained sobriety during that time and ~1.5 yr post stopping. was on 68-72 mg/d
-start 30 mg today. Increase dose by 10 mg QD up to 60 mg daily. then may increase by 5 mg up to 70 mg/d. consider further increase if persistent w/d, cravings
-narcan education and kit given
-f/u in 1 M or sooner prn

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