Daily IP Prog Note

Pt was seen and evaluated in the presence of BH staff. [checkbox name="team" value="Pt was discussed with an interdisciplinary team, consisting of attending and resident psychiatrists, social work, and nursing staff."]

Per overnight report, pt [select name="medications" value="remains compliant with medications as prescribed,|is non-compliant with medications, "] [checkbox name="events" value="required therapeutic hold|required seclusion |required restraints|required PRN medications|did not require staff interventions"] overnight.

Pt is a [text name="Age"] y/o [select name="Gender" value="cis-male|cis-female|trans-male|trans-female|non-binary"], on day [text name="number"] of current admission. Pt was initially admitted due to concerns of [text name="symptoms"].

Pt was encountered [select name="location" value="at the bedside|in the common area|in the hallway"] and was observed [text name="activity"]. On encounter, pt appeared [text name="appearance"]. 

Pt reports that since yesterday [textarea name="changeofsymptoms"].

Pt reports mood as [text name="mood"].
Pt reports sleep as [select name="sleep" value="good|fair|poor|none"].
Pt reports appetite as [select name="appetite" value="good|fair|poor|none"].

Safety Assessment:
[checklist name="safetyassessment" value="suicidal ideation|homicidal ideation|auditory hallucinations|visual hallucinations"]

Somatic Concerns:
Neuro: [checkbox name="neuro" value="headaches|dizziness|seizures|denies"]
Head: [checkbox name="head" value="visual changes|drooling|congestion|dental pain|denies"]
CVP: [checkbox name="cvp" value="chest pain|palpitations|shortness of breath |wheezing|coughing|denies"]
GI: [checkbox name="GI" value="constipation|diarrhea|cramping|abdominal pain|denies"]
Urinary: [checkbox name="urinary" value="incontinence|retention|dysuria |polyuria|denies"]
MSK: [checkbox name="msk" value="body pains|muscular cramping|weakness|gait changes|denies"]
Pt was seen and evaluated in the presence of BH staff.

Per overnight report, pt overnight.

Pt is a y/o , on day of current admission. Pt was initially admitted due to concerns of .

Pt was encountered and was observed . On encounter, pt appeared .

Pt reports that since yesterday
.

Pt reports mood as .
Pt reports sleep as .
Pt reports appetite as .

Safety Assessment:


Somatic Concerns:
Neuro:
Head:
CVP:
GI:
Urinary:
MSK:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.67, 21 form elements, 71 boilerplate words, 6 text boxes, 1 text areas, 8 checkboxes, 1 check lists, 5 drop downs, 52 total clicks
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