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"].
Response to TX: [checkbox name="variable_2" value="Engaged|Uninterested|Cooperative|Combative"]
Mental Status Examination:
General: [select name="variable_2" value="alert and oriented in all spheres|obtunded|disoriented"].
Appearance: [select name="variable_3" value="well kempt|poorly kempt|appropriately dressed|inappropriately dressed|appropriately groomed|inappropriately groomed"].
Behavior - general: [select name="variable_4" value="in no acute distress|in acute psychological distress"].
Behavior - stability: [select name="variable_5" value="calm|agitated"].
Behavior - interactivity: [select name="variable_6" value="warm with comments and behavior|interactive|withdrawn"].
Behavior - eye contact: [select name="variable_7" value="eye contact good|eye contact fair|eye contact avoidant"].
Mood/Affect - stated: [select name="variable_8" value="normal|upbeat|euthymic|depressed"].
Mood/Affect - emotional range: [select name="variable_9" value="normal|broad|restricted"].
Mood/Affect - intensity: [select name="variable_10" value="normal|expansive|blunted|flat"].
Mood/Affect - congruence: [select name="variable_11" value="mood is congruent with affect|mood and affect are not congruent"].
Thought form and content: [select name="variable_12" value="normal|future oriented|logical, linear and goal-oriented|past oriented and somber|goal directed|scattered|hopeful|remorseful|enthusiastic|resigned"]
Attention: [select name="variable_13" value="no difficulty with attention or concentration|had some attentional and concentration problems during the exam"].
Perception - insight: [select name="variable_14" value="normal insight|poor insight"]
Perception - general: [select name="variable_15" value="normal|hallucinations - auditory|hallucinations - auditory, talking to someone not present|hallucinations - visual|hallucinations - visual - looking at something not present|hallucinations - multiple"]
Cognition/Memory: [select name="variable_16" value="normal|grossly intact|below average|above average"].
Cognition/Memory - abstraction: [select name="variable_17" value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"]
Judgment: [select name="variable_18" value="normal|poor|good"].
Suicide/Assault: [select name="variable_19" value="no current or past ideation or intent|denies an active sense of wanting to harm self or others|present but without intent or plan|resolved"].
Patient is currently assessed to be at [select name="variable_20" value="low|moderate|high"] risk for self harm or harm to others as evidenced by ideation and behavior on today's exam.
Treatment Interventions: [checkbox name="ebt" value= "CBT|EMDR|CPT|PE|Mindfulness-based|Behavioral activation|TF-CBT|Solution-Focused Therapy|DBT skills|Other"]

Changes in diagnosis or treatment plan: [text box="changes" value="None"]

Therapist will utilize the following therapeutic modality at next session: [checkbox name="ebt" value= "CBT|EMDR|CPT|PE|Mindfulness-based|Behavioral activation|TF-CBT|Solution-Focused Therapy|DBT skills"]
Focus of next session: [textarea="" rows="1"]
Therapist will also review [checkbox name="checkon" value="homework/outside assignment|recent stressors/emotional experiences|symptom intensity/frequency|goal achievement/outcomes"] with client at next visit.

Homework: Ct agreed to [checkbox name="homework" value="reflect on psychoeducation topics/materials covered in today's session|engage in journaling/reflective note taking as discussed in session|create daily routine to encourage self care, behavioral activation, and organization|consistently commit to daily routine/behavioral activation schedule|establish healthy boundaries with friends/family using techniques discussed and roleplayed during session|discuss healthy communication skills with family/friends, as outlined in communication skills work complete in session|utilize CBT skills (reframing/challenging/replacing negative thoughts)|engage in self directed exposure therapy/incremental training around specific anxieties as discussed in session|decrease catastrophic thinking by engaging in behavioral experiments and tracking progress|engage in mindfulness/stress reduction techniques as practiced in therapy (deep breathing, meditation, guided imagery)|experiment with at least one new self care activity this week and reflect in journal/planner|practice distress tolerance skills as rehearsed in therapy|implement coping skills consistently when dysregulated|tracking mood, and triggers for mood fluctuations|following safety plan if in crisis|track success and progress toward goals|devise a regular and adequate eating schedule, a pattern of adequate sleep and relaxation, as well as regular cardiovascular exercise"]Other: [text name="homework" default=""]
-Follow Up in [text name="variable_1" default=""] week for continued psychotherapy
-The patient will contact emergency services for after hour care

The patient is a year old who presents to the clinic for . The patient has a diagnosis of .
Response to TX:
Mental Status Examination:
General: .
Appearance: .
Behavior - general: .
Behavior - stability: .
Behavior - interactivity: .
Behavior - eye contact: .
Mood/Affect - stated: .
Mood/Affect - emotional range: .
Mood/Affect - intensity: .
Mood/Affect - congruence: .
Thought form and content:
Attention: .
Perception - insight:
Perception - general:
Cognition/Memory: .
Cognition/Memory - abstraction:
Judgment: .
Suicide/Assault: .
Patient is currently assessed to be at risk for self harm or harm to others as evidenced by ideation and behavior on today's exam.
Treatment Interventions:

Changes in diagnosis or treatment plan:

Therapist will utilize the following therapeutic modality at next session:
Focus of next session:

Therapist will also review with client at next visit.

Homework: Ct agreed to Other:
-Follow Up in week for continued psychotherapy
-The patient will contact emergency services for after hour care

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.84, 37 form elements, 158 boilerplate words, 4 text boxes, 1 text areas, 8 checkboxes, 19 drop downs, 2 comments, 3 conditionals, 85 total clicks
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