Follow-up visit for [text name="visit" default=""]. Chart reviewed. Labs reviewed. Case discussed with staff. Patient seen and examined [checkbox name="variable_3" value="in hospital room on medical floor.|on unit.|on post-partum floor.| on rounds with Dr. Sharpe."] [checkbox name="variable_5" value="Sitter is at bedside, but steps out for interview."] Present during interview: [checkbox name="variable_6" value="Sitter|Security|RN|Care staff|Spouse|Family|Friend|Patient is alone"]. INTERVAL HISTORY: [textarea name="IntervalHx" default=" "] Appetite: normal/no problems reported Sleep: normal/no problems reported[_ ] Energy: normal[_] HI: denies on interview, no evidence/report per discussion with staff SI: denies on interview, no evidence/report per discussion with staff Aggression/Agitation: not currently[___] AH/VH: denies AH, denies VH Delusions: Patient is: [___ able ___ not able to contract for safety ___N/A]. Medication Side Effects (SE): [ ] MENTAL STATUS EXAM Level of Consciousness: [Alert, drowsy, lethargic, non-arousable] Appearance: [____________________________] Gait:[ _______________________________________] Manner: [___ Cooperative ___ Guarded ___ Suspicious ___ Irritable ___ Hostile ___Withdrawn ___ Other ] Psychomotor Activity: [ ___ Normal ___ Agitation ___ Motor Retardation ___ Tremor ___ Abnormal movement] Musculoskeletal: [ ___ Normal ___ Rigidity ___ Cogwheel ___Flaccid ___Tics/TD ___ Other] Speech: [___ Normal ___ Soft/Loud ___ Slow/Pressured ___ Dysarthric ___ Incoherent ___Other ] Language: [___ Normal ___Expressive Aphasia ___Fluent Aphasia ___ Other ____. Appropriateness of conversation, rate of speech (> 100 words per minute is normal; < 50 words per minute is abnormal), reading and writing appropriate to education level] Fund of Knowledge: [_______Intact ________Fair ________ Poor __________Other] Mood: [ ___ Euthymic ___ Depressed ___ Irritable ___Angry ___ Anxious ___ Fearful ___ Apathetic ___ Euphoric ___Other] Affect: [ ___ Euthymic ___Depressed ___Blunted ___Flat ___Irritable ___ Angry ___Anxious ___Labile ___Expansive ___Exaggerated ___Other ] Thought Process/Association:[ ___Normal ___Tangential ___Circumstantial ___Poverty of Thought ___Concrete ___Disorganized ___Racing Thoughts ___Flight of Ideas ___ Loose ___Other] Thought Contents: [___Normal ___Hopelessness ___Worthlessness ___Hypochondriasness ___Delusions ___Paranoia ___Ruminations ___Confused ___Obsessions/Compulsions ___Other] Perception: [ ___ Normal, [ ___Hallucinations ___Auditory ___Visual ___Olfactory ___Tactle ___ Command Hallucinations],[ ___Dissociation ___Flashbacks ___Other Attention/Concentration: [___Intact ___Poor ___Distractible ___Redirectable ___Other ] Cognition: [___Intact ___Impaired Insight: ___Intact ___Fair ___Limited] Short Term Memory: [___Intact ___Fair ___Poor Judgment: ___Intact ___Fair ___Limited] Remote Memory:[ ___Intact ___Fair ___Poor] PSYCHOTHERAPY/ COUNSELING: [ ___Therapeutic Interview ___ Supportive ___ CBT ___ Ongoing ___Other] ASSESSMENT: Patient is:[ ___ Well-controlled ___ Improving ___ Worsening ___ Other DIAGNOSES: [ ] TREATMENT/PLAN: [___ Continue Current Medications ___Continue Follow-Up ___Continue Labs ___ Other] [Risks, benefits, Side Effects, Drug-to-Drug Interactions and Alternatives to treatment were discussed in my usual manner: ____ Yes ____No] Reason for not reducing medication dose(s): [____N/A ____ High risk of patient’s deterioration ___ Medication recently reduced ___Prior Medication Dose Reduction Unsuccessful ____Other ] Complexity Issues: [# of diagnoses or management options: ____Limited ____Multiple ] [Problems: (gait, hearing, vision, etc.) effect on treatment and management: ____Yes ____ No] [Risk of complications and/or morbidity or mortality: ____None ____ Limited ____ Moderate ____ Severe] [Coord. of Care (e.g. with patient and/or family, social workers, nursing staff, other doctors): ____None ____>50% of visit ____<50% of visit] Topics discussed: ___Nature of diagnosis and/or prognosis ___Aspects of aging process and relationship to the current problem ___Nature of possible treatment options/drug drug interaction ___Risk of non-treatment ___Psychopharmacologic treatment options/possible benefits and risks ___Nature of, reasons for and possible benefits from psychotherapy ___Family and/or situational stressors ___Behavioral and/or environmental changed that might help Additional considerations/activities: ___ Medical records reviewed ___Communication with patient’s Dr ___Communication with facility staff ___Communication with family/caregiver ___Referred for psychotherapy ___ Forms/reports filled out ___OtherFollow-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."]
There are 18 form elements.