cree/Keife/inital

Keife Earley
8:07 PM (0 minutes ago)
to me

Date: [date name="variable_1_date" default="03-20-2023"]
Time: [text name="variable_1_time" default="sample text"]

The patient consents to treatment and consultation via telemedicine (remote video visit); the patient was informed of the limitations of telemedicine; oral and written consent was received

[text name="variable_2" default="sample text"] is AGE [text name="variable_3" default="sample text"] [select name="variable_4_gender" value="female|male|nonbinary|she|they|he|him|them"] who presents for an initial psychiatric evaluation with chief concerns of ADHD.

HISTORY OF PRESENT ILLNESS:
Age of symptom onset[text name="variable_5" default="sample text"]
History of impairment and any former treatment[textarea name="variable_6" default="sample text"]
Current symptoms and current functional impairments across settings[select name="variable_7" value="Home|Work|School|Church|Social Settings"]

PSYCHIATRIC REVIEW OF SYSTEMS:
ADHD:
ASRS- A Evaluation Score: [text name="variable_8" default="sample text"]
Patient ENDORSES [textarea name="variable_9" default="sample text"] # out of 9 inattentive symptoms of ADHD as occurring often or very often, including[checklist name="variable_10" value="problems following through on directions|unfinished tasks|difficulty with organization|is often forgetful|reluctance to engage in tasks requiring sustained attention|failing to give close attention to details/ careless mistakes|difficulty sustaining attention|problems listening when spoken to directly|misplaces things necessary for tasks and activities|easily distracted by extraneous stimuli"]

Patient ENDORSES[textarea name="variable_11" default="sample text"] # out of 9 hyperactivity symptoms of ADHD as occurring often or very often, including [checkbox name="variable_12" value="fidgets/squirms|always on the go, driven by a motor|often leaves seat when remaining seated is expected|restlessness|trouble engaging in leisure activities|talks excessively|blurts out answers/completes other people sentences|difficulty waiting their turn|interrupts or intrudes on others"]

DEPRESSION:
PHQ-9 Score:[text name="variable_13" default="sample text"]
Patient [select name="variable_14" value="DENIES|ENDORSES"] symptoms of DEPRESSION including
[checkbox name="variable_15" value="loss of interest in pleasurable activities|sad mood and feelings of hopelessness|sleep alteration|problems with energy|appetite disturbance|feelings of guilt or worthlessness|problems with concentration|psychomotor disturbance|passive suicidal thoughts"]

ANXIETY:
GAD-7 Score:[text name="variable_16" default="sample text"]
Patient [select name="variable_17" value="DENIES|ENDORSES"]symptoms of GENERALIZED ANXIETY, including[checklist name="variable_18" value="excessive worrying throughout the day associated with,|feeling nervous and on edge|constant worry|racing thoughts|trouble relaxing|feeling restless|Irritability|feelings of impending doom"]
Triggers: [textarea name="variable_19" default="sample text"]

PANIC:
Patient [select name="variable_20" value="ENDORSES|DENIES"]symptoms of PANIC ATTACKS
Triggers:[textarea name="variable_21" default="sample text"]
Frequency:[checklist name="variable_22" value="Daily|Weekly|Monthly"]

INSOMNIA:
Sleep routine:[textarea="variable_23" default="sample text"]
Hours of sleep per night:[text name="variable_24" default="sample text"]
Patient [select name="variable_25" value="ENDORSES|DENIES"] symptoms of INSOMNIA, including [checkbox name="variable_26" value="difficulty falling asleep|frequent awakenings during the night|difficulty staying asleep|waking up too early|non-restorative sleep|daytime sleepiness|difficulty concentrating due to lack of sleep"]

SUBSTANCE USE:
Patient [select name="variable_27" value="ENDORSES|DENIES"] current or past substance use. If endorsed, please specify: [textarea name="variable_28" default="sample text"]

PAST PSYCHIATRIC HISTORY:
Previous diagnoses:[textarea name="variable_29" default="sample text"]
Previous treatments (medications and/or therapy):[textarea name="variable_30" default="sample text"]
Response to previous treatments:[textarea name="variable_31" default="sample text"]

FAMILY PSYCHIATRIC HISTORY:
Family history of psychiatric disorders:[textarea name="variable_32" default="sample text"]

SOCIAL HISTORY:
Occupation:[text name="variable_33" default="sample text"]
Marital status:[select name="variable_34" value="Single|Married|Divorced|Widowed|Separated"]
Living situation:[text name="variable_35" default="sample text"]
Support system:[textarea name="variable_36" default="sample text"]

MENTAL STATUS EXAM:
Appearance:[textarea name="variable_37" default="sample text"]
Mood:[text name="variable_38" default="sample text"]
Affect:[text name="variable_39" default="sample text"]
Speech:[text name="variable_40" default="sample text"]
Thought process:[textarea name="variable_41" default="sample text"]
Thought content:[textarea name="variable_42" default="sample text"]
Perception:[textarea name="variable_43" default="sample text"]
Cognition:[textarea name="variable_44" default="sample text"]
Insight and judgment:[textarea name="variable_45" default="sample text"]

ASSESSMENT AND PLAN:
DSM-5 Diagnoses:[textarea name="variable_46" default="sample text"]
Treatment recommendations:[textarea name="variable_47" default="sample text"]
Follow-up plan:[textarea name="variable_48" default="sample text"]

RECOMMENDED FOLLOW-UP:
Provider and patient can communicate asynchronously via the "Consultations" tab on Done. website. Patients can also follow up as needed with the provider by scheduling a video follow-up appointment. This Provider would AT LEAST need the patient to schedule a video follow-up appointment every 6 months in order to closely monitor their progress and continue to safely provide medication management.

*********************  Additional Notes  ******************

Patient’s preferred Pharmacy-verified and updated in the chart.
ID verification verified

Side Effect Education:
Re: Stimulants: Side effects of stimulants can include decreased appetite, insomnia particularly if taken too late in the day, dry mouth, tics, tremor, agitation or psychosis, changes in libido, elevated heart rate, and blood pressure. Dangerous side effects could include psychotic sx, seizures, cardiovascular events and arrhythmia. There is an increased risk of arrhythmia or cardiovascular problems in persons with a personal history of cardiac disease or stroke or a family history of cardiac or stroke at an early age or sudden death. There is a risk of worsening or side effects of glaucoma, vision changes or eye pain. Stimulants have a risk of dependency and addiction. People can develop tolerance necessitating increases in doses. if possible, it is helpful to take the medication only on days in which it is needed

Informed Consent:
Psychoeducation provided as to the benefits, risks, side effects, and alternatives to the patient’s medication treatment plan. 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 9-1-1 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. It is recommended that the patient should discuss this diagnosis and treatment plan with their PCP as well, 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 verbalizes understanding, agrees to this treatment plan, and agrees to coordinate care as needed.

LaCresha Earley PMHNP BC, FNP-C, APRN