Follow Up Final_4

Telemedicine was performed per regulatory requirements as the practice of health care delivery, diagnosis, consultation and treatment and the transfer of medical data between the originating and distant sites. The patient expressed understanding of the information provided regarding telehealth/telemedicine, all of their questions have been answered to the patient's satisfaction and verbal informed consent for the use of telehealth/telemedicine was provided to this provider. Patient has a right to rescind the use of telecommunication recording at any time.

Patient has provided consent to begin evaluation and treatment for this individual. Services are being performed in the language of the patients choosing.

Patient presents to Ascend Healthcare today [select name="variable_1" value="virtually, via Zoom|virtually, via alternative method|via audio call"], [select name="variable_2" value="alone|with their mother|with their father|with both parents|with their partner|with their legal guardian"] for evaluation and continued medication management. 

Today, patient reports the following symptoms as stable and/or improving:
[checkbox value="anxiety related|depression|mood|mania related|OCD related|psychotic|sleep disturbances|trauma related|ADHD related|substance use related"]
[textarea memo="other" default="" rows="1"].

Today, patient reports the following symptoms as worsening or cause for concern:
[checkbox value="anxiety related|depression|mood|mania related|OCD related|psychotic|sleep disturbances|trauma related|ADHD related|substance use related"]
[textarea memo="other" default="" rows="1"].

[textarea name="variable_1" memo="HPI info" default="\n\n\n"]

Current Medications:
[text name="med_1"]
[text name="med_2"]
[text name="med_3"]
[text name="med_4"]
Current progress in achieving treatment goals can best be characterized as [checkbox value="appropriate|poor|moderate|significant"][textarea memo="other" default="" rows="1"].
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" rows="1"][textarea memo="additional benefits" rows="1"].[/conditional] 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('')"]
Patient [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]
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="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.

Diagnoses:
[text]
[text]
[text]
[text]
[text]
PAST MEDICATIONS:
[text]
[text]
[text]
[text]
[text]
CURRENT MEDICATIONS:
[text name="med_1"]
[text name="med_2"]
[text name="med_3"]
[text name="med_4"]
REVIEW/MANAGEMENT
If appropriate and available, I reviewed previous notes, labs, imaging, and consults.[checkbox value="I reviewed PMP|and found no abnormal results.|and found abnormal results "][textarea default="" rows="1"]

I discussed risks vs. benefits, as well as side effects with the patient, reviewed alternative treatments, including no treatment, and answered any questions. Medications have been discussed with parents or legal guardians. The patient and/or parent or legal guardian received medication information in the form of a medication information handout if available. 

Allergies, Medical, Social and Psychiatric Histories were reviewed and updated.

REVIEW OF SYSTEMS: Pertinent items are noted in HPI; remainder of 10-point review of systems performed and noted to be negative.

Psych: SEE MSE 
PHYSICAL EXAM: Constitutional- awake, alert, no apparent distress 

ASSESSMENT: Patient presenting today with a psychiatric problem that that has caused marked impairment in aspects of their daily life with impairment in daily functioning. Patient’s chart/records have been reviewed and summarized. Additional work-up of psychotherapy services is recommended to patient. Patient presentation warrants use of psychiatric medication to improve symptoms and to reduce risk of decompensation.  

Presentation today of: MODERATE complexity F/U (99214)

PLAN:
1. Rx: See above.
2. Labs: Ordered as warranted
3. CSPMP reviewed as warranted
4. Patient and/or guardian educated on increased risks/SE of prescriptions with concurrent use of ETOH and illicit substances including risks of profound sedation, CNS depression and death. Side effects profiles of prescriptions were reviewed at length including but not limited to Nausea/Vomiting/Headaches/GI Distress/Drug-Drug interactions/Seizure threshold reduction/Serotonin Syndrome/SJS/Cardiac abnormalities/Black box warnings/Neuroleptic Malignant Syndrome/CNS Depression. Patient and/or guardian is able to verbally express understanding and consent to treatment.
5. Additional work up planned: Patient encouraged to engage in psychotherapy and support services as well as follow up with PCP or specialist as needed for medical treatment.
6. Patient is to follow up at next scheduled appointment or sooner and is welcome to return at any time
7. F/U with PCP or specialist as needed for medical treatment. SE/risks/benefits explained, informed consent to treat obtained. Patient educated and informed to either return for follow up or seek emergency treatment as appropriate should they have any of the following: questions or concerns about prescriptions; side effects; worsening psychiatric symptoms; suicidal or homicidal ideation. The patient was able to express understanding of treatment plan and utilize resources within the community to keep themselves/others safe and notify clinic of any changes to their current medical/psychiatric status. Pertinent side effects profiles were reviewed at length including but not limited to N/V/Headaches/GI distress/drug-drug interactions/seizure threshold reduction/Serotonin Syndrome/SJS/cardiac abnormalities/black box warnings/CNS Depression/Abuse and Misuse/Profound sedation and death/Risks of concomitant use of medication with ETOH or other substances and patient is able to verbally express understanding and consent to treatment.
Telemedicine was performed per regulatory requirements as the practice of health care delivery, diagnosis, consultation and treatment and the transfer of medical data between the originating and distant sites. The patient expressed understanding of the information provided regarding telehealth/telemedicine, all of their questions have been answered to the patient's satisfaction and verbal informed consent for the use of telehealth/telemedicine was provided to this provider. Patient has a right to rescind the use of telecommunication recording at any time.

Patient has provided consent to begin evaluation and treatment for this individual. Services are being performed in the language of the patients choosing.

Patient presents to Ascend Healthcare today , for evaluation and continued medication management.

Today, patient reports the following symptoms as stable and/or improving:

other.

Today, patient reports the following symptoms as worsening or cause for concern:

other.

HPI info

Current Medications:




Current progress in achieving treatment goals can best be characterized as
other.
The patient would benefit from
additional benefits.[/conditional] Potential barriers for success include
additional barriers.[/conditional] Strengths to Success:
Patient . Education Provided

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.

Diagnoses:





PAST MEDICATIONS:





CURRENT MEDICATIONS:




REVIEW/MANAGEMENT
If appropriate and available, I reviewed previous notes, labs, imaging, and consults.


I discussed risks vs. benefits, as well as side effects with the patient, reviewed alternative treatments, including no treatment, and answered any questions. Medications have been discussed with parents or legal guardians. The patient and/or parent or legal guardian received medication information in the form of a medication information handout if available.

Allergies, Medical, Social and Psychiatric Histories were reviewed and updated.

REVIEW OF SYSTEMS: Pertinent items are noted in HPI; remainder of 10-point review of systems performed and noted to be negative.

Psych: SEE MSE
PHYSICAL EXAM: Constitutional- awake, alert, no apparent distress

ASSESSMENT: Patient presenting today with a psychiatric problem that that has caused marked impairment in aspects of their daily life with impairment in daily functioning. Patient’s chart/records have been reviewed and summarized. Additional work-up of psychotherapy services is recommended to patient. Patient presentation warrants use of psychiatric medication to improve symptoms and to reduce risk of decompensation.

Presentation today of: MODERATE complexity F/U (99214)

PLAN:
1. Rx: See above.
2. Labs: Ordered as warranted
3. CSPMP reviewed as warranted
4. Patient and/or guardian educated on increased risks/SE of prescriptions with concurrent use of ETOH and illicit substances including risks of profound sedation, CNS depression and death. Side effects profiles of prescriptions were reviewed at length including but not limited to Nausea/Vomiting/Headaches/GI Distress/Drug-Drug interactions/Seizure threshold reduction/Serotonin Syndrome/SJS/Cardiac abnormalities/Black box warnings/Neuroleptic Malignant Syndrome/CNS Depression. Patient and/or guardian is able to verbally express understanding and consent to treatment.
5. Additional work up planned: Patient encouraged to engage in psychotherapy and support services as well as follow up with PCP or specialist as needed for medical treatment.
6. Patient is to follow up at next scheduled appointment or sooner and is welcome to return at any time
7. F/U with PCP or specialist as needed for medical treatment. SE/risks/benefits explained, informed consent to treat obtained. Patient educated and informed to either return for follow up or seek emergency treatment as appropriate should they have any of the following: questions or concerns about prescriptions; side effects; worsening psychiatric symptoms; suicidal or homicidal ideation. The patient was able to express understanding of treatment plan and utilize resources within the community to keep themselves/others safe and notify clinic of any changes to their current medical/psychiatric status. Pertinent side effects profiles were reviewed at length including but not limited to N/V/Headaches/GI distress/drug-drug interactions/seizure threshold reduction/Serotonin Syndrome/SJS/cardiac abnormalities/black box warnings/CNS Depression/Abuse and Misuse/Profound sedation and death/Risks of concomitant use of medication with ETOH or other substances and patient is able to verbally express understanding and consent to treatment.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.53, 61 form elements, 712 boilerplate words, 19 text boxes, 8 text areas, 8 checkboxes, 22 drop downs, 1 comments, 3 conditionals, 103 total clicks
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