F/U Objective and MSE
This outpatient medication check was conducted[select name="variable_1" value=" via phone appointment.| via telepsychiatry.| in person. |OTHER|"] Patient reports doing[select name="variable_2" value=" better| worse| well| good | slightly worse | slightly better| about the same"] since the last visit.[text name="variable_10953" default=""] Medication has[select name="variable_21" value=" helped with psychiatric symptoms.| no effect on psychiatric symptoms.| made psychiatric symptoms worse.| not changed psychiatric symptoms.| not helped psychiatric symptoms due to not taking the medication. | made psychiatric symptoms slightly worse.| somewhat of an effect."] [text name="variable_8231" default=""] Sleep is[select name="variable_2161" value=" increased| better | worse| decreased| somewhat better| not changed| at baseline and good overall"]. [text name="variable_6241" default=""] Anxiety is [select name="variable_34731" value="nonexistent.|mild.|decreasing|increasing|somewhat better.|moderate.|severe.|somewhat worse|better.|worse."][text name="variable_39921" default=" "] Depression is [select name="variable_343001" value="nonexistent.|mild.|decreasing.|increasing.|somewhat better.|moderate.|severe.|somewhat worse.|better.|worse."][text name="variable_39921" default=" "] Appetite is[select name="variable_45671" value=" about the same.| worse.| getting slightly worse.|getting slightly improving.| decreasing| increasing| better."][text name="variable_5241" default=""] Suicidal ideation:[select name="variable_431" value=" no suicidal ideation and contracts for safety.| suicidal ideation but contracts for safety and will not act on it.| suicidal ideation and can not contract for safety."][text name="variable_1" default=""] Self harm: [select name="variable_69691" value="no self harm.||self harm recently and does not contract for safety.| self harm recently."][text name="variable_1" default=""] Homicidal ideation: [select name="variable_4561" value=" no homicidal ideation.| homicidal ideation.|"] Patient[select name="variable_7891" value=" denies hallucinations.| has hallucinations in the form of |no hallucinations but|"][text name="variable_52241" default=""] Patient [select name="variable_7791" value=" denies delusions.| has delusions in the form of|denies delusions but does have paranoia|"][text name="variable_52141" default=""] Patient states[select name="variable_2561" value=" no mood swings.|mood swings are somewhat getting better.| mood swings are about the same.| mood swings are manageable| decrease in mood swings.| increase in mood swings."][text name="variable_2881" default=""] The patient [select name="variable_2551" value="denied symptoms of mania.|denied symptoms of hypomania.|states symptoms of hypomania.| states symptoms of mania.|denied symptoms of mania since last visit.|states decrease in symptoms of mania|states increase in symptoms of mania"][text name="variable_28181" default=""] Concentration is[select name="variable_252251" value=" good.| worse| better| doing better with medication.| fair. | poor.|"][text name="variable_281811" default=""] [comment memo="Appearance: Unable to assess. Orientation: Alert and oriented. Memory: Intact. Motor: Unable to assess. Eye contact: Unable to assess. Attention: Intact. Speech: Within normal limits. Mood: Euthymic. Affect: Appropriate to mood. Thought process: Linear. Thought content: No paranoia, delusions or perceptual disturbances. Suicidal ideations: None. Homicidal ideations: None. Insight: Good. Judgment: Good."] [comment memo=" General Appearance: Appears stared age. Behavior/ Attitude: Cooperative. Psychomotor Activity: Normal. Speech: All Normals. Mood: Normal. Affect: Normal. Thought Process: Normal. Thought Content: Normal. Orientation: Normal Recent & Remote Memory: Normal. Concentration: Normal. Fund of Knowledge: Good. Insight: Normal. Judgment: Normal. Musculoskeletal; Normal. Grooming: Well Groomed. Alertness: Alert."] [comment memo="Pt was called twice and did not return phone call for medication management appointment. At this time the patient needs to reschedule their appointment."]
There are 31 form elements.
Result - Copy and paste this output:
More SOAPnotes by this Author: