Follow up note – copy
REVIEW OF SYSTEMS CONSTITUTIONAL: [comment memo="*" memo_size="small" memo_color="blue"][conditional field="GENexamdetailed" condition="(GENexamdetailed).isNot('')"][text default="denies fatigue, changes in weight, chronic pain, fever or chills." size="80"][/conditional][checkbox name="GENexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="GENexamdetailed" condition="(GENexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="fatigue|weight gain|weight loss|chronic pain|fever|chills"][/conditional] CARDIAC: [comment memo="*" memo_size="small" memo_color="blue"][conditional field="CARexamdetailed" condition="(CARexamdetailed).isNot('')"][text default="denies chest pain, palpitations, dizziness or syncope." size="80"][/conditional][checkbox name="CARexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="CARexamdetailed" condition="(CARexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="chest pain|chest pressure|palpitations|dizziness|syncope"][/conditional] RESPIRATORY: [comment memo="*" memo_size="small" memo_color="blue"][conditional field="REexamdetailed" condition="(REexamdetailed).isNot('')"][text default="denies cough, shortness of breath, wheezing or use of supplemental oxygen." size="80"][/conditional][checkbox name="REexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="REexamdetailed" condition="(REexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="cough|dry cough|productive cough|shortness of breath at rest|shortness of breath on exertion|wheezing|use of supplemental oxygen"][/conditional] GI: [comment memo="*" memo_size="small" memo_color="blue"][conditional field="GIexamdetailed" condition="(GIexamdetailed).isNot('')"][text default="denies abdominal pain, nausea, vomitting, diarrhea or constipation." size="80"][/conditional][checkbox name="GIexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="GIexamdetailed" condition="(GIexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="abdominal pain|nausea|vomitting|diarrhea|constipation|acid reflux"][/conditional] PSYCH: [comment memo="*" memo_size="small" memo_color="blue"][conditional field="PSYexamdetailed" condition="(PSYexamdetailed).isNot('')"][text default="denies any changes in mood, depression, anxiety, sleep disturbance or problems with substance or alcohol use." size="80"][/conditional][checkbox name="PSYexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="PSYexamdetailed" condition="(PSYexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="mood changes|depression|anxiety|panic attacks|insomnia|hypersomnolence|attention issues|alcohol use|substance use"][/conditional] PHYSICAL EXAM [checkbox name="vitals" memo="*" memo_size="small" memo_color="blue" value="-Vitals Review"][conditional field="vitals" condition="(vitals).is('-Vitals Review')"] - [select value="reviewed, no remarkable abnormalities|significant for"][text size="50"] [/conditional]GENERAL:[comment memo="*" memo_size="small" memo_color="blue"][conditional field="GENexamdetailed" condition="(GENexamdetailed).isNot('')"][text default="well developed, well nourished, no apparent distress" size="80"][/conditional][checkbox name="GENexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="GENexamdetailed" condition="(GENexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="well developed|well nourished|A&Ox4|NAD"] [checkbox value="MILDLY ILL|SLEEPY|APPEARS CONFUSED|APPEARS LETHARGIC|CACHECTIC APPEARANCE|APPEARS OLDER THAN STATED AGE"][/conditional] HEENT: [comment memo="*" memo_size="small" memo_color="blue"][conditional field="HEENTexamdetailed" condition="(HEENTexamdetailed).isNot('')"][text default="normocephalic, atraumatic, nares patent, mucous membranes moist" size="80"][/conditional][checkbox name="HEENTexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="HEENTexamdetailed" condition="(HEENTexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="normocephalic|atraumatic|conjunctiva clear|sclerae aninteric|TMs with clearly visible landmarks|nares patent b/l|turbinates nonedematous/nonerythematous b/l|mucous membranes moist|throat nonerythematous/noninjected|good dentition"] [checkbox value="R CONJUNCTIVAL ERYTHEMA|L CONJUNCTIVAL ERYTHEMA"][/conditional] NECK: [comment memo="*" memo_size="small" memo_color="blue"][conditional field="NECKexamdetailed" condition="(NECKexamdetailed).isNot('')"][text default="no gross distention, no visible overt defect" size="80"][/conditional][checkbox name="NECKexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="NECKexamdetailed" condition="(NECKexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="soft/supple|no JVD|no thyromegaly|no tender/enlarged lymph nodes"] [checkbox value="R ANTERIOR CHAIN LYMPHADENOPATHY|R POSTERIOR CHAIN LYMPHADENOPATHY|L ANTERIOR CHAIN LYMPHADENOPATHY|L POSTERIOR CHAIN LYMPHADENOPATHY|JUGULAR VENOUS DISTENSION|GOITER"][/conditional] PSYCH: [comment memo="*" memo_size="small" memo_color="blue"][conditional field="PSYCHexamdetailed" condition="(PSYCHexamdetailed).isNot('')"][text default="appropriate mood/affect" size="80"][/conditional][checkbox name="PSYCHexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="PSYCHexamdetailed" condition="(PSYCHexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="appropriate mood|appropriate affect|FLATTENED AFFECT|INAPPROPRIATE MOOD|PRESSURED SPEECH|DISORGANIZED THOUGHT PROCESS|TANGENTIAL THOUGHT PROCESS"][/conditional] NEURO: [comment memo="*" memo_size="small" memo_color="blue"][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).isNot('')"][text default="mentation normal/appropriate, no gross/overt cranial nerve deficits" size="80"][/conditional][checkbox name="NEUROexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="mentating well|moves all extremities equally well|CN 2-12 grossly intact b/l|normal sensorium all 4 extremities|no gross motor deficits|Romberg negative|cerebellar testing normal|DTRs 2/4 x4|gait testing without abnormalities"][/conditional][conditional field="examNEUROabn1|examNEUROabn2|examNEUROabn3|examNEUROabn4|examNEUROabn5|examNEUROabn6" condition="((examNEUROabn1).is(' -Cranial Nerve Deficit(s)- '))||((examNEUROabn2).is(' -Sensory Deficit(s)- '))||((examNEUROabn3).is(' -Motor Strength-'))||((examNEUROabn4).is(' -Reflexes-'))||((examNEUROabn5).is(' -Cerebellar Testing-'))||((examNEUROabn6).is(' -Gait- '))"] [/conditional][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][comment memo="abnormals" memo_size="small" memo_color="orange"][checkbox name="examNEUROabn1" value=" -Cranial Nerve Deficit(s)- "][/conditional][conditional field="examNEUROabn1" condition="(examNEUROabn1).is(' -Cranial Nerve Deficit(s)- ')"] [checkbox value="I|II|III|IV|V|VI|VII|VIII|IX|X|XI|XII"] [/conditional][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][checkbox name="examNEUROabn2" value=" -Sensory Deficit(s)- "][/conditional][conditional field="examNEUROabn2" condition="(examNEUROabn2).is(' -Sensory Deficit(s)- ')"][checkbox name="examNEUROabn11" value="R occipital|R parietal|R temporal|R frontal|R preauricular|R postauricular|L occipital|L parietal|L temporal|L frontal|L preauricular|L postauricular|R mandibular angle|R cheek|R nasal bridge|R periorbital|R perioral|chin|submental|R submandibular|L mandibular angle|L cheek|L nasal bridge|L periorbital|L perioral|L submandibular|Neck anterior|Neck posterior|Neck medial|Neck lateral|R shoulder|L shoulder|Anterior chest/trunk|Posterior chest/trunk|Abdomen|R buttocks|L buttocks|Perianal|Gluteal cleft|R inguinal|L inguinal|Penis|R scrotum|L scrotum|R labia majora|R labia minora|R perilabial area|L labia majora|L labia minora|L perilabial area|periclitoral area|mons pubis|perineum|R arm|R elbow|R forearm|R wrist|R hand/finger(s)|L arm|L elbow|L forearm|L wrist|L hand/finger(s)|R hip|R thigh|R knee|R leg|R ankle|R foot/toe(s)|L hip|L thigh|L knee|L leg|L ankle|L foot/toe(s)"] [text memo="description of deficits" memo_size="small" memo_color="yellow" size="80"] [/conditional][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][checkbox name="examNEUROabn3" value=" -Motor Strength-"][/conditional][conditional field="examNEUROabn3" condition="(examNEUROabn3).is(' -Motor Strength-')"] -R Upper Extremity- [text default="5" size="5"]/5 -L Upper Extremity- [text default="5" size="5"]/5 -R Lower Extremity- [text default="5" size="5"]/5 -L Lower Extremity- [text default="5" size="5"]/5 [/conditional][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][checkbox name="examNEUROabn4" value=" -Reflexes-"][/conditional][conditional field="examNEUROabn4" condition="(examNEUROabn4).is(' -Reflexes-')"] -Biceps- [text default="2+" size="5"]/4 -Triceps- [text default="2+" size="5"]/4 -Bracioradialis- [text default="2+" size="5"]/4 -Patellar- [text default="2+" size="5"]/4 -Achilles- [text default="2+" size="5"]/4 [/conditional][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][checkbox name="examNEUROabn5" value=" -Cerebellar Testing-"][/conditional][conditional field="examNEUROabn5" condition="(examNEUROabn5).is(' -Cerebellar Testing-')"] [checkbox value="POSITIVE ROMBERG|PRONATOR DRIFT|IMPAIRED FINGER-TO-NOSE|IMPAIRED HAND PRONATE/SUPINATE|IMPARIED HEEL-TO-SHIN"] [text memo="cerebellar deficits freetext" memo_size="small" size="80"] [/conditional][conditional field="NEUROexamdetailed" condition="(NEUROexamdetailed).is('')"][checkbox name="examNEUROabn6" value=" -Gait- "][/conditional][conditional field="examNEUROabn6" condition="(examNEUROabn6).is(' -Gait- ')"][checkbox value="HEMIPLEGIC|DIPLEGIC|NEUROPATHIC|CHOREIFORM|ATAXIC|PARKINSONIAN|ANTALGIC"] [/conditional] [text name="name" memo="Patient name" size="20"] is a [text memo="age" size="2"]-year-old,[checkbox value="single|married|partnered"] [checkbox value="cis-gender female|cis-gender male|transgender female|transgender male|gender non-binary individual"][text memo="other gender" value="20"] who presents to Elevate Health and Wellness today [select name="variable_1" value="in person|virtually, via Doxy|via Facetime|via audio call"], [select name="variable_2" value="alone|with their parent(s)|with their partner"] for evaluation and continued medication management. They were last seen on [date name="variable_27" default="12-06-2022"] and [checkbox value="the following medication changes were made during that visit: |no changes were made to the patients medication during the last visit"][textarea memo="other" default="" rows="1"]. Today, [var name="name"] [select value="presents with new symptoms of| presents with worsening symptoms of|denies new or worsening symptoms|reports improved symptoms of|reports"] [checkbox value="depression|anxiety|sleep disturbance|psychosis|substance use disorder|cognitive impairment|attention challenges|impulsivity|mood lability|alcohol dependence|opioid dependence|autism spectrum disorder"][textarea memo="other" default="" rows="1"]. [checkbox name="depression" memo="depression" value=""][checkbox name="anxiety" memo="anxiety" value=""][checkbox name="sleep" memo="sleep" value=""][checkbox name="mood" memo="mood" value=""][checkbox name="adhd" memo="adhd" value=""][conditional field="depression" condition="(depression).is('')"] [var name="name"]'s depression is described as [checkbox value="little interest or pleasure in doing things|hopelessness|helplessness|sleeping too much|difficulty getting to sleep|difficulty staying asleep|feeling tired or having little energy|poor appetite|overeating|feelings of inadequacy|inappropriate guilt|irritability|poor concentration|psychomotor retardation|psychomotor agitation|suicidal ideation"]. [select value="Depressive symptoms are present most of the day, nearly every day|Depressive symptoms are mostly present |"][text size="20"][select value=". Symptoms are exacerbated by |"][text size="20][select value=", and improved by |"][text size="20]. Client rates depression [select value="1|2|3|4|5|6|7|8|9|10"]/10 with 10 being the worst.[textarea memo="Additional Depression information" rows="5"][/conditional] [conditional field="anxiety" condition="(anxiety).is('')"] [var name="name"]'s anxiety generally presents as [checkbox value="feeling nervous or on edge|excessive worry|difficulty relaxing|feeling restless|difficulty getting to sleep|difficulty staying asleep|irritability|poor appetite|overeating|panic attacks"][text size="20]. [select value="Anxiety is present |"][select value="present at all times|intermittently present in response to external stressors|in the context of multiple different situations/events such as |primarily in social situations such as "][textarea rows="1"]. [select value="Anxiety occurs |Anxiety is present most of the time on most days"][text size="20"][select value=", is brought on by |"][text size="20][select value=", is relieved by |"][text size="20]. Client rates anxiety [select value="1|2|3|4|5|6|7|8|9|10"]/10 with 10 being the worst. [textarea memo="Additional Anxiety information" rows="5"][/conditional][conditional field="mood" condition="(mood).is('')"] [select value=" Mood instability has been an issue since |"][text size="20"]. [select value="Disordered mood presents as |"][checkbox value="euphoria|excessive energy|excessive self-confidence|insomnia|irritability|agitation|racing thoughts|impulsive behavior|risk taking behavior|paranoia|delusions of grandeur|auditory hallucinations|visual hallucinations|depression|apathy|hopelessness|helplessness|suicidal thoughts|no motivation|hypersomnia"]. [select value="Mood lability is exacerbated by |There are no identified precipitating factors to mood lability|"][textarea rows="1"]. [textarea memo="additional information of mood lability" rows="4"][/conditional][conditional field="autism" condition="(autism).is('')"] [select value="Per patient,|Per family,|Per record,|"][text size="20"][select value=" they have been | patient has been |"][select value="diagnosed|undiagnosed|"][text size="20"][select value=" autism spectrum disorder "][textarea memo="details of diagnosis/symptom timeframe" rows="4"]. [var name="name"]'s symptoms present as persistent difficulty, in multiple contexts, with social communication and interaction including: [checkbox value="abnormal or failed back and forth conversation|failure to initiate or respond to social interactions|reduced sharing of interests/emotions|limited emotional affect|limited/incongruent nonverbal communication|difficulty with developing/maintaining/understanding relationships|difficulty sharing imaginative play|limited or absent interest in peers"]. They have demonstrated restricted/repetitive patterns of behavior, interests, or activities including: [checkbox value="repetitive motor movements|repetitive speech|infexible adherence to routines|ritualized patterns of verbal or nonverbal behavior|significant difficulty with transitions|rigid thinking patterns|highly restricted and fixated interests|hyper-reactivity to sensory input|hyporeactivity to some sensory input"]. Presentation is [select value="without|with"] intellectual impairment, and [select value="without|with"] language impairment. [textarea rows="4"][/conditional][conditional field="adhd" condition="(adhd).is('')"] [var name="name"] has a pattern of [checkbox name=addtype value="inattention and hyperactivity/impulsivity|inattention|hyperactivity/impulsivity"] that interferes with functioning. [/conditional][conditional field="addtype" condition="(addtype).is('inattention and hyperactivity/impulsivity')||(addtype).is('inattention')"] Inattention manifests as [checkbox memo="At least 6 for ADHD" value="poor attention to details or careless mistakes in work or activities|difficulty sustaining attention|not seeming to listen when spoken to directly|not following through on instructions or failing to finish tasks|having difficulty organizing tasks and activities|avoiding tasks that require sustained mental effort|frequently losing things necessary for tasks|often easily distracted by extraneous stimuli|forgetfulness in daily activities"].[/conditional] [conditional field="addtype" condition="(addtype).is('inattention and hyperactivity/impulsivity')||(addtype).is('hyperactivity/impulsivity')"] [var name="name"]'s hyperactivity/impulsivity presents as [checkbox memo="six or more for ADHD" value="frequent fidgeting or squirming|often leaving seat when remaining seated is expected|frequently restless|difficulty engaging in leisure activities quietly|often seeming to be on the go or difficult to keep up with|excessive talking|blurting out answers before a question has been completed|difficulty waiting for their turn|interrupting or intruding on others"].[/conditional][conditional field="adhd" condition="(adhd).is('')"] These symptoms have been present since [text memo="before 12yo" size="20"], and are recognized in multiple settings including [text memo="2 or more" size="20"]. [textarea rows="3"] [/conditional][conditional field="sleep" condition="(sleep).is('')"] Sleep is reported to be generally [select name="sleepq" value="poor |fair |good.|erratic |inconsistent |excessive|"][select value="with difficulty initiating sleep and staying asleep due to |with difficulty initiating sleep due to |with difficulty maintaining sleep due to |"][textarea rows="2"]. They estimate getting approximately [text size="4"] hours of [select value="broken |solid |"]sleep per night. [select value="Disturbed sleep has been an issue for |Disturbed sleep is a new issue within the last |"][textarea rows="1"]. [select value="There has been no workup for Sleep Apnea|There was a past workup for sleep apnea which indicated |"][textarea rows="1"]. [select value="Current attempts at improving sleep include |The patient is currently attempting no interventions to improve sleep|Current quality of sleep is dependent on |"][textarea rows="2"]. [select value="Past unsuccessful attempts at improving sleep include |There have been no past attempts at improving sleep|"][textarea rows="2"]. [/conditional] [var name="name"]'s progress in achieving treatment goals can best be characterized as [checkbox value="minimal|minimal due to resistance|making some progress|working on goals, but remains symptomatic"][textarea memo="other" default="" rows="1"]. [checkbox name="bene" memo="The patient would benefit from:" value=""][conditional field="bene" condition="(bene).is('')"]The patient would benefit from [checkbox value="initiation of psychopharmaceutical intervention|continuation of current medication regimen|adjustments to current medication regimen|initiation of psychotherapy|continuation of current psychotherapy|engaging in grief therapy|engaging in CBT|engaging in family therapy|enhanced psychosocial supports|increasing personal time and self-care" rows="1"].[/conditional] [checkbox name="barrier" memo="Barriers to Success:" value=""][conditional field="barrier" condition="(barrier).is('')"]Potential barriers for success include [checkbox value="current apprehension to engage in psychopharmaceutical intervention|current apprehension to engage in structured psychotherapy|non-compliance with medications|limited social supports|dysfunctional interpersonal relationships|conflict in interpersonal relationship with partner|peer conflict|financial stressors|trauma reminders|school stressors|life transitions|work related stressors|medication management issues|medication changes|cormorbid physical health issues|grief/loss|lack of financial resources|risk-taking behaviour|unemployment|strained familial relationships"][textarea memo="additional barriers" rows="1"].[/conditional] [checkbox name="str" memo="Strengths to Success:" value=""][conditional field="str" condition="(str).is('')"]The patients strength(s) for success include [checkbox value="expression of willingness to engage in treatment recommendations|positive social supports|strong therapeutic rapport|history of actively engaging in mental-health treatment"][textarea memo="additions strengths" rows="1"].[/conditional] [var name="name"] [select value="denies wanting medication changes at this time|is open to considering further medication adjustments for the treatment of |is requesting medication adjustments today for treatment of "][text name="variable_1" default=""].[checkbox name="edu" memo="Education Provided" value=""][conditional field="edu" condition="(edu).is('')"] Psychopharmacological education furnished with the patient consenting to [textarea name="variable_1" default=""] [/conditional] [conditional field="A" condition="(A).is('Followup')"][comment memo="1pt each, 2pt for summary"][/conditional] [checkbox value="I reviewed the following notes:"][textarea default="" rows="1"][conditional field="A" condition="(A).is('Followup')"][comment memo=" 1pt each, 2pts for summary"][/conditional] [checkbox value="I reviewed the following labs, imaging, consults:"] [textarea default="" rows="1"][conditional field="A" condition="(A).is('Followup')"][comment memo=" 1pt each, 2pts for summary"][/conditional] [checkbox value="I obtained collateral information from: "] [textarea default="" rows="1"][conditional field="A" condition="(A).is('Followup')"][comment memo=" 2pts each"][/conditional] [checkbox value="I consulted with: "][textarea memo=" individual and reason for consultation" default="" rows="1"] [checkbox value="I reviewed PMP|and found no abnormal results|and found the following abnormal results: "][textarea default="" rows="1"] PLAN The patient will [checkbox name="homework" value="take medication(s) as prescribed|continue regular meetings with current therapist|establish care with an outpatient therapist|maintain sobriety|reflect on psychoeducation topics/materials covered in today's session| engage in journaling/reflective note| create daily routines to encourage self care, behavioral activation, and organization| consistently commit to daily routine/behavioral activation schedule| establish healthy boundaries with friends/family| utilize CBT skills (reframing/challenging/replacing negative thoughts)| engage in mindfulness/stress reduction techniques (deep breathing, meditation, guided imagery)| experiment with at least one new self care activity this week | practice distress tolerance skills| implement coping skills consistently when dysregulated| track mood, and triggers for mood fluctuations| follow safety plan if in crisis"] [text name="variable_a" default=","] [checkbox name="variable_22" value="The following blood work was ordered today:"] [conditional field="variable_1" condition="condition to test"] [text name="variable_99" default="."] [checkbox name="variable_23" value="Updated rating scales sent to the patient via Therapy Notes portal to be completed prior to next visit."] The patient will devise a regular and adequate eating schedule, a pattern of adequate sleep and relaxation, as well as regular cardiovascular exercise. The next appointment is scheduled for date [date name="variable_8" default="12-05-2022"]
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Sandbox Metrics: Structured Data Index 0.57, 260 form elements, 84 boilerplate words, 41 text boxes, 34 text areas, 2 dates, 67 checkboxes, 31 drop downs, 8 variables, 25 comments, 52 conditionals, 483 total clicks
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