Comprehensive Follow up for Psychiatry 1
S/B DEPT OF PSYCHIATRY, Dr. [text] INFORMANT: [text] REFERRED BY: [text default="none"] DIAGNOSED CASE OF: [text default="none"] CHIEF COMPLAINT: [text] INTERCURRENT HISTORY: [textarea][/textarea] [remark]ROS section start[/remark][checkbox name="pmh" value="PAST MEDICAL HISTORY:"][conditional field="pmh" condition="(pmh).is('PAST MEDICAL HISTORY:')"][textarea][/textarea][/conditional] [remark]ROS section start[/remark][checkbox name="ros" value="REVIEW OF SYSTEMS:"][conditional field="ros" condition="(ros).is('REVIEW OF SYSTEMS:')"][textarea]As above in Intercurrent hisotry. Other pertinent constitutional symptoms, HEENT symptoms, cardiac symptoms, respiratory symptoms, gastrointestinal symptoms reviewed and negative[/textarea][/conditional] [remark]allergies and medications section start[/remark][checkbox name="allmed" value="ALLERGIES AND MEDICATIONS:"][conditional field="allmed" condition="(allmed).is('ALLERGIES AND MEDICATIONS:')"] [textarea][/textarea][/conditional] [remark]Physical section start[/remark][checkbox name="phy" value="PHYSICAL EXAM:"][conditional field="phy" condition="(phy).is('PHYSICAL EXAM:')"][textarea]T: normal P: /min RR: /min BP /mmhg Systemic examination: no focal abnormalities[/textarea][/conditional] [remark]MSE section start[/remark][checkbox name="mse" value="MSE:"][conditional field="mse" condition="(mse).is('MSE:')"]</br>Appearance: [select value="alert and oriented to time, place and person|OBTUNDED|DISORIENTED|HYPERALERT|-"], [select value="well kempt|POORLY KEMPT|appropriately dressed|INAPPROPRIATELY DRESSED|appropriately groomed|INAPPROPRIATELY GROOMED|DISHEVELED|-"], [select value="normal posture|SLUMPED|RIGID|TENSE|-"]. [textarea cols="20" rows="1"][/textarea] Behavior: [select value="calm|RESTLESS|AGITATED|RETARDED|PECULIAR|IMPULSIVE|-"], [select value="interactive|WITHDRAWN|-"], [select value="eye contact good|eye contact AVOIDANT|eye contact INTENSE|eye contact FLEETING|-"]. [textarea cols="20" rows="1"][/textarea] Attitude: [select value="cooperative|HOSTILE|OVER FRIENDLY|SECRETIVE|EVASIVE|SUSPICIOUS|APATHETIC|EASILY DISTRACTED|FOCUSED|DEFENSIVE|DEMANDING|SEDUCTIVE|-"]. [textarea cols="20" rows="1"][/textarea] Speech: [select name="spontn" value="spontaneous|NON-SPONTANEOUS|MUTISM|-"], [select name="rt" value="N reaction time|INCR REACTION TIME|DECR REACTION TIME|VARIABLE|-"], [select name="rate" value="normal rate|SLOW|POVERTY|PAUCITY|RAPID|OVERTALKATIVE|PRESSURE|-"], [select name="vol" value="normal volume|LOUD|SOFT|WHISPHER|MONOTONE|-"], [select name="rhythm" value="clear rhythm|SLURRED|HESITANT|APHASIC|-"].[textarea cols="20" rows="1"][/textarea] Mood reported as: [textarea cols="20" rows="1"][/textarea], inferred as-[select value="euthymic|NOT REPORTED|ANXIOUS|DEPRESSED|DYSPHORIC|IRRITABLE|ELEVATED|EXPANSIVE|ELATED|EUPHORIC|ANGRY|HOSTILE|INDIFFERENT|DETACHED|ANIMATED|-"] Affect: quality: [select value="euthymic|ANXIOUS|DEPRESSED|DYSPHORIC|IRRITABLE|ELEVATED|EXPANSIVE|ELATED|EUPHORIC|ANGRY|HOSTILE|INDIFFERENT|DETACHED|ANIMATED|-"], [select value="range normal|BROAD|RESTRICTED|-"], [select value="intensity normal|EXPANSIVE|BLUNTED|FLAT|LABILE|-"], [select value="congruent|INCONGRUENT|-"]. [textarea cols="20" rows="1"][/textarea] Thought form: [select value="coherent|INCOHERENT|CANNOT BE ASSESSED|NOT ENOUGH SAMPLE|-"], [select value="logical and goal directed|-|CIRCUMSTANTIAL|TANGENTIAL|LOOSENING|FLIGHTS OF IDEAS"]. [select value="-|NEOLOGISM|BLOCKING|VERBAL PERSEVERATION"]. [textarea cols="20" rows="1"][/textarea] Thought content: [select value="no delusion on current evaluation|DELUSION PRESENT|CANNOT BE ASSESSED|-"], [select value="no active suicidal ideations at present| SUICIDAL IDEATIONS PRESENT|DEATH WISHES PRESENT|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="1"][/textarea] Perception: [select value="no hallucination on current evaluation|HALLUCINATION|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="1"][/textarea] Insight: [select value="present|PARTIAL|POOR|MOSTLY BLAMES OTHERS|DIFFICULTY IN ACKNOWLEDGING PRESENCE OF PSYCHIATRIC SYMPTOMS|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="1"][/textarea] Judgment: [select value="intact|IMPAIRED|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="1"][/textarea] Cognition: [select value="intact|ABNORMALITIES PRESENT|PENDING|CANNOT BE ASSESSED|-"]. [textarea default="normal attention, concentration, intact ability to recall recent and remote information, normal abstraction" cols="50" rows="3"][/textarea][/conditional] [remark]Assessment section start[/remark][checkbox name="assm" value="ASSESSMENT/PLAN:"][conditional field="assm" condition="(assm).is('ASSESSMENT/PLAN:')"][textarea]pt counseled refer omit add increase rest ct same x follow up after [/textarea][/conditional]
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0.58, 67 form elements, 16 boilerplate words, 5 text boxes, 18 text areas, 6 checkboxes, 26 drop downs, 6 remarks, 6 conditionals, 55 total clicks
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