EJProgress Note

HISTORY OF PRESENTING PROBLEM[conditional field="A" condition="(A).is('Followup')"][comment memo="
99212 requires 1 HPI
99213 requires 1 HPI + pertinent ROS
99214 requires 4 HPI + pertinent ROS plus one other + 1 P/F/S hx
99215 requires 4 HPI + complete ROS + 2 P/F/S hx"][/conditional][conditional field="A" condition="(A).is('Intake')"][comment memo="
Intake = 90792"][/conditional]
[conditional field="A" condition="(A).is('Intake')"][/conditional]
The patient is a [text name="variable_1" default=""] year old [checkbox name="variable_1" value="male |female |non-binary"] who presents to the clinic for [checkbox name="variable_1" value="an inital psychotherapy intake|follow-up psychotherapy appointment"]. The patient has a diagnosis of [checkbox name="variable_1" value="anxiety disorders |depression disorders |personality disorder | schizophrenia | attachment disorder | sleep disturbances | Bipolar | OCD | ADHD/ADD | PTSD | Eating disorder | mood disorder"]. The Patient remains [comment memo="SYMPTOM"][checkbox value="depressed|anxious|aggressive|impulsive|inattentive|irritable|withdrawn|unable to sleep|delusional|auditory hallucinations|visual hallucinations"][textarea memo="other" default="" rows="1"].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"]

*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="denied | Headaches|weakness|disturbed sleep"][textarea memo="other" default="" rows="denied"]
GI - [checkbox value="denied | Upset stomach|nausea|constipation|heatburn"][textarea memo="other" default="" rows="1"]
[checkbox name="variable_1" value="Currently Denies SI/HI/Self-harm | Currently Denies SI/HI, endorses self harm |Currently denies HI, endorses SI/self-harm | Endorses SI, denies self-harm/HI"]
With:
[checkbox name="variable_1" value="with no plan or intent|has an active plan"]
All other systems negative

PHYSICAL EXAMINATION
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="Within Normal Limits | Full range |sad|tearful|anxious|flattened|restricted|irritable|happy"][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"]

[comment memo="Psychiatric Add On
Psychotherapy/Interactive Complexity/Prior case management
"][checkbox value="Time spent in psychotherapy: "][checkbox value="16-37 min"][comment memo="30 min 90833"][checkbox value="38-52 min"][comment memo="45 min 90836"][checkbox value="53-67 min"][comment memo="60 min 90838"]
[checkbox value="Focus of psychotherapy: "][checkbox value="interpersonal conflict|emotional experience related to diagnosis|identification of coping mechanisms|grief counseling"][textarea memo="other" default="" rows="1"]
[checkbox value="Modality: "][checkbox value="insight oriented|supportive|behavioral modification"][textarea memo="other" default="" rows="1"]

REVIEW/MANAGEMENT
*Problem Status*[comment memo="
Problem status: Established-stable/improved=1pt each 
Established-worsening=2pt each 
New problem, no additional workup planned=3pt (only one) 
New problem, additional workup planned=4pt"]
The patient's progress in achieving treatment goals can best be characterized as: [checkbox value="minimal|patient is resistant|patient is making some progress|patient is working on goals, but remains symptomatic"][textarea memo="other" default="" rows="1"]


Diagnosis:[comment memo="Indicate whether diagnosis changed, reason for change, date and time of change"][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="5"]

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 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="continuation of current psychotherapy | continued psychopharmaceutical intervention|adjustments to current psychopharmaceutical intervention|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="fair|good|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="5"]

PLAN: 
-Continue working with Psychiatrist
-The patient a demonstrated her journal taking during therapy and agreed to continue in journaling/reflective note-taking as discussed in the session, create a daily routine to encourage self-care, behavioral activation, and organization, consistently commit to daily routine/behavioral activation schedule|The patient will continue to think about joining a group therapy
-Follow Up in [text name="variable_1" default=""] week for continued psychotherapy
-The patient will contact emergency services for after hour care
-Discussed coping mechanisms and patient agreed to work on taking a step back and thinking before reacting
HISTORY OF PRESENTING PROBLEM

The patient is a year old who presents to the clinic for . The patient has a diagnosis of . The Patient remains SYMPTOM
other.
Which is described asSEVERITY
other
The patient notices that it is sometimes improved by Modifying factors
other

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

With:

All other systems negative

PHYSICAL EXAMINATION
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

Psychiatric Add On
Psychotherapy/Interactive Complexity/Prior case management
30 min 90833 45 min 90836 60 min 90838
other
other

REVIEW/MANAGEMENT
*Problem Status*
Problem status: Established-stable/improved=1pt each
Established-worsening=2pt each
New problem, no additional workup planned=3pt (only one)
New problem, additional workup planned=4pt

The patient's progress in achieving treatment goals can best be characterized as:
other


Diagnosis:Indicate whether diagnosis changed, reason for change, date and time of change


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.


PLAN:
-Continue working with Psychiatrist
-The patient a demonstrated her journal taking during therapy and agreed to continue in journaling/reflective note-taking as discussed in the session, create a daily routine to encourage self-care, behavioral activation, and organization, consistently commit to daily routine/behavioral activation schedule|The patient will continue to think about joining a group therapy
-Follow Up in week for continued psychotherapy
-The patient will contact emergency services for after hour care
-Discussed coping mechanisms and patient agreed to work on taking a step back and thinking before reacting

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.62, 105 form elements, 234 boilerplate words, 2 text boxes, 32 text areas, 32 checkboxes, 23 drop downs, 13 comments, 3 conditionals, 213 total clicks
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