Follow Up Psych Note – ABBREV

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]

Patient presents to this outpatient follow-up appointment [select value="in person|virtually, via Doxy|with parent|with partner|with friend|with family"] for continued evaluation and management of [checkbox value="major depressive disorder|generalized anxiety disorder|insomnia|attention deficit disorder|bipolar disorder|substance use disorder|PTSD|social anxiety|obsessive compulsive disorder|borderline personality disorder|suicidal ideation|schizoaffective disorder|sleep disturbance"][text]. Patient was last seen on [date].  Since that time they have [textarea]. 
[checkbox memo="Depression" name="dep" value=""][checkbox memo="Anxiety" name="anx" value=""][checkbox memo="ADHD" name="adhd" value=""][checkbox memo="Sleep" name="sleep" value=""][conditional field="anxiety" condition="(anxiety).is('')"][/conditional][conditional field="dep" condition="(dep).is('')"]Depressive symptoms are reported to be [select value="stable|significantly better|somewhat better|somewhat worse|much worse| "][text].  [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|situational stressors|incorporation of self care|engaging in individual therapy|decrease in use or abstaining from substance use"][textarea].  Depression is rated at [select value="1|2|3|4|5|6|7|8|9|10"]/10 with 10 being the worst.  [textarea][/conditional][conditional field="anx" condition="(anx).is('')"]

Anxiety is reported to be [select value="stable|significantly better|somewhat better|somewhat worse|much worse| "][text].  [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|lack of response to medications|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea].  Anxiety is reported to be present [select value="occasionally|mostly around situational stressors|almost never|about 50% of the time|most of the time on most days|almost always|"][text].  Anxiety is rated at [select value="1|2|3|4|5|6|7|8|9|10"]/10 with 10 being the worst.  [textarea][/conditional][conditional field="adhd" condition="(adhd).is('')"]

ADHD symptoms are reported to be [select value="stable|better|somewhat better|somewhat worse|much worse| "][text].  [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|lack of response to medications|situational stressors|behavioral changes|engaging in individual therapy"][textarea].  Inattention is reported to be present [select value="occasionally|mostly around situational stressors|almost never|about 50% of the time|most of the time on most days|almost always|"][text].  [textarea][/conditional][conditional field="sleep" condition="(sleep).is('')"]

Sleep is reported to be [select value="stable|better|somewhat better|somewhat worse|much worse| "][text].  [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|lack of response to medications|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea].  Insomnia is reported to be present [select value="occasionally|mostly around situational stressors|almost never|about 50% of the time|most of the time on most days|almost always|"][text].  [textarea][/conditional][conditional field="mood" condition="(mood).is('')"]

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|increase in frequency of therapy sessions|engaging in CBT|engaging in family therapy|enhanced psychosocial supports|improvements in diet|regular exercise"]. 
[checkbox value="Barriers to success include: "][checkbox value="current apprehension to engage in psychopharmaceutical intervention|current apprehension to engage in structured psychotherapy|current substance use|limited social supports|dysfunctional interpersonal relationships"][textarea memo="barriers" rows="1"]. [checkbox value="Patient strength for success include: "][checkbox value="expression of willingness to engage in treatment recommendations|positive social supports|strong therapeutic rapport|daily medication compliance"][textarea memo="strengths" rows="1"].  [textarea rows="5"]
[select value="They deny wanting medication changes at this time|They are open to considering further medication adjustments for the treatment of |They are requesting medication adjustments for treatment of |"][text].  [textarea]
REVIEW OF SYSTEMS

CONSTITUTIONAL: * more detail
CARDIAC: * more detail
RESPIRATORY: * more detail
GI: * more detail
PSYCH: * more detail

PHYSICAL EXAM

*GENERAL:* more detail
HEENT: * more detail
NECK: * more detail
PSYCH: * more detail
NEURO: * more detail

Patient presents to this outpatient follow-up appointment for continued evaluation and management of . Patient was last seen on . Since that time they have .
Depression Anxiety ADHD Sleep

Patient would benefit from .
barriers. strengths.
.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.55, 180 form elements, 42 boilerplate words, 31 text boxes, 23 text areas, 1 dates, 48 checkboxes, 16 drop downs, 21 comments, 40 conditionals, 331 total clicks
Questions/General site feedback

Send Feedback for this SOAPnote

This site uses Akismet to reduce spam. Learn how your comment data is processed.

More SOAPnotes by this Author: