Follow-up visit for [checkbox name="variable_1" value="suicidal ideation|suicide attempt|depression|anxiety|mood disorder|bipolar disorder|somatic symptoms|agitation|delirium|dementia|dementia with behavioral disturbances|AMS|psychosis|substance abuse|substance withdrawal|patient on 6404|patient on 6401|re-evaluation of capacity|re-evaluation of need for geripsych|re-evaluation of need for emergency psychiatric hospitalization"].
[checkbox name="variable_2" value="First time seeing patient, case discussed with handing off provider."]
Chart/labs/imaging/assessments reviewed. Interval events discussed with staff. [select name="variable_2" value="In the past 24 hours|In the past 48 hours|Since admission"], patient [select name="variable_3" value="has|has not"] required psychiatric PRNs [textarea name="variable_2" default="-"], [select name="variable_4" value="has|has not"] required restraints[textarea name="variable_3" default=""], [select name="variable_5" value="has|has not"] endorsed suicidal ideation [textarea name="variable_4" default=""], and [select name="variable_6" value="has|has not"] required involvement of security [textarea name="variable_5" default=""].
[select name="variable_1" value="Per nursing|Per tech| Per staff|Per report from primary team |Per case management|Per attending|Reportedly|Per review of interval notes"],[textarea name="variable_1" default=" today the patient has been appropriate, cooperative with care and treatment, eating/drinking OK, not agitated and not appearing to respond to internal stimuli."]
[checkbox name="variable_3" value="Patient seen for follow-up in hospital room on medical floor|Patient seen for follow-up on unit| Dr. Sharpe also in attendance| RN present during interview|sitter at bedside, but steps out for interview|sitter at bedside during interview|security present during interview"]. Family/friends [select name="variable_7" value="are at bedside|are not currently at bedside but were reportedly here earlier|are not at bedside|are not at beside and have reportedly not been involved during admission"].
There are 15 form elements.
Result - Copy and paste this output: