FU PROG

START TIME: [text name="Name" default=""]

IDENTIFYING INFORMATION: [text]-year-old [select name="variable_1" value="male|female"] who lives in [text] presenting [select name="variable_8985" value="face-to-face|with consent for telemedicine visit from home|with consent for telemedicine visit outside of home"] for [text]-month follow-up for continued management of [checkbox name="variable_2899" value="depression|anxiety|panic|ADHD|PTSD|OCD|bipolar disorder|insomnia|psychosis|personality disorder|dementia|neurocognitive concerns|IED|schizoaffective disorder|schizophrenia|intellectual disability|PMDD|ASD|anorexia|bulimia|social_anxiety"]. Information provided by the client, who is a reliable source and good historian.

REFERRED BY: [text]

CHIEF COMPLAINT: [text]

HISTORY OF PRESENT ILLNESS: Client presents with a significant and lengthy history of [checkbox name="variable_2899" value="depression|anxiety|panic|ADHD|PTSD|OCD|bipolar disorder|insomnia|psychosis|personality disorder|dementia|neurocognitive concerns|IED|schizoaffective disorder|schizophrenia|intellectual disability|PMDD|ASD|anorexia|bulimia|social_anxiety"]. At the last visit, [select name="variable_5" value="she|he"] [select name="variable_4" value="reported stability in symptoms and denied the need for changes in treatment regimen|voiced concerns of increased symptoms, wherein|voiced concerns of no significant change in symptoms, wherein|reported some improvement, but remained symptomatic|noted significant improvement"] [text]. [select name="variable_45" value="She|He"] is currently prescribed [textarea memo="other" default="" rows="1"]. Today, [select name="variable_5" value="she|he"] reports 
[checkbox name="variable_6" value="significant improvement|significant worsening of symptoms|no significant change in symptoms|some positive gains|stability in symptoms|continued stability in symptoms"]. 
[checkbox name="depression" memo="depression" value=""][checkbox name="anxiety" memo="anxiety" value=""][checkbox name="panic" memo="panic" value=""][checkbox name="ADHD" memo="ADHD" value=""][checkbox name="PTSD" memo="PTSD" value=""][checkbox name="OCD" memo="OCD" value=""][checkbox name="bipolar" memo="bipolar disorder" value=""][checkbox name="psychosis" memo="psychosis" value=""][checkbox name="alcohol" memo="alcohol" value=""][checkbox name="opioid" memo="opioid" value=""][checkbox name="personality" memo="personality" value=""][checkbox name="neuro" memo="neurocognitive" value=""][checkbox name="IED" memo="IED" value=""][checkbox name="schizoaffective" memo="schizoaffective" value=""][checkbox name="schizophrenia" memo="schizophrenia" value=""][checkbox name="anorexia" memo="anorexia" value=""][checkbox name="anorexia" memo="anorexia" value=""][checkbox name="bulimia" memo="bulimia" value=""][checkbox name="social_anxiety" memo="social_anxiety" value=""][checkbox name="dementia" memo="dementia" value=""][conditional field="depression" condition="(depression).is('')"][select value="No concerning progression of depressive symptoms|Depression has improved|There are no notable changes in depressive symptoms|Depression is reporetedly worse"]; [checkbox value="denying loss of interest/pleasure, hopelessness, helplessness, feelings of inadequacy, low energy/fatigue, poor appetite, irritability, impaired concentration, psychomotor changes|loss of interest/pleasure|hopelessness|helplessness, feelings of inadequacy|low energy/fatigue|poor appetite|irritability| impaired concentration|psychomotor changes"].[/conditional][conditional field="anxiety" condition="(anxiety).is('')"] [select value="Anxiety is manageable, no panic attacks;|There are no significant changes in anxious symptoms and continues to experience|Anxiety is improving, but continues to struggle with|Anxiety is worsening with related increase in|Anxiety is currently exacerbated with increased"] [checkbox value="no excess worry, racing thoughts, restlessness, impaired concentration, becoming easily overwhelmed, irritability, muscle tension|excess worry over routine things|restlessness|difficulty concentrating due to racing thoughts|becoming easily overwhelmed|irritability|muscle tension|headaches"].[/conditional][conditional field="panic" condition="(panic).is('')"] Panic attacks are [select value="cued by|unexpected"] [text] and accompanied by [checkbox value="palpitations|tachycardia|sweating|trembling/shaking|SOB|chest tightness|nausea/stomach cramps|numbness/tingling|fear of losing control|feeling closed in and overwhelmed|chills|heat sensations"], occuring [text] and lasting approximately [text] minutes. Symptoms are sometimes improved by [text].[textarea memo="Additional information" rows="1"][/conditional][conditional field="ADHD" condition="(ADHD).is('')"] [select value="Reports ADHD symptoms are stable;|ADHD symptoms are unchanged and remains symptomatic|ADHD symptoms are improving, but continues to struggle with|ADHD symptoms are worse with increased"]; reports [checkbox value="some inattention and forgetfulness, but no careless mistakes, difficulty following conversations and sitting still, becoming easily sidetracked/distracted by unrelated thoughts, avoiding/procrastinating, reduced patience.|inattention|careless mistakes|difficulty sustaining attention|problems following conversations|easily side tracked|difficulty organizing tasks/activities|avoidance and procrastination|forgetfulness|easily distracted by unrelated thoughts|fidgeting|inability to relax|excessive talking|difficulty waiting/reduced patience"].[/conditional][conditional field="PTSD" condition="(PTSD).is('')"][select value="Denies|Continues to experience|Increased"] [checkbox value="nightmares|flashbacks|intrusive memories/thoughts|avoidance|negative affect|loss of interest|isolation|difficulty experiencing positive emotions|irritability/annoyance|risky/self-destructive behaviors|hypervigilance|heightened startle reaction"].[/conditional] [conditional field="OCD" condition="(OCD).is('')"][select value="No recurring thoughts/images/urges/behaviors or mental rituals that induce counteractive urges to reduce distress and necessitate perpetual reassurance.|Endorses"] [checkbox value="recurring thoughts/images|urges|repetitive behaviors|counting|focusing on geometry|checking|isolation|organizing/aligning objects|hoarding|fear of germs/illness|blinking|touching/tapping|needing constant reassurance|fear of dread|mental rituals|excessive time spent thinking or engaging in compulsive behavior"]. [/conditional][conditional field="bipolar" condition="(bipolar).is('')"][select value="Stable mood; no lability, increased self-esteem/speech/distractibility/energy/desire/sociality/impulsivity, loss of sleep, difficulty keeping up with thoughts.|Some mood fluctuations with associated|Increased emotional lability,"]  [checkbox value="elevated mood|irritability|increased self-esteem|pressured speech|feeling more distracted|increased energy|increased desire|more social/outgoing|increased impulsivity|loss of sleep|difficulty keeping up with thoughts"]. [/conditional]
[conditional field="psychosis" condition="(psychosis).is('')"]
Reports [checkbox value="Delusions of persecution|jealous delusions|somatic delusions|grandiose delusions|religious delusions|thought broadcasting|thought insertion|auditory hallucinations|visual hallucinations|disorganized thoughts|disorganized behaviors|confusion|social isolation|loss of motivation|problems focusing|suicidal thoughts"]. [/conditional][conditional field="neuro" condition="(neuro).is('')"] Cognitive symptoms are [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"] with reports of [checkbox value="difficulty with complex attention|poor executive functioning|difficulty with short term memory|difficulty with long term memory|motor difficulties|confusion|repetitive behaviors|misplacing objects|difficulty understanding context|difficulty formulating speech|forgetting names/words|loss of interest|confusion|social isolation|loss of motivation|paranoia|visual hallucinations|auditory hallucinations|obsessive behaviors|hoarding behaviors|tremors|night terrors|sleeping during the day|not sleeping at night|agitation|threatening behaviors|inappropriate behaviors"].[/conditional][conditional field="alcohol" condition="(alcohol).is('')"]
Alcohol use is [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Client reports [checkbox value="no concerning progression of alcohol use|daily drinking|drinking more than anticipated|inability to cut down on drinking|cravings to drink|blackouts|hangovers|urges to drink|missing work due to drinking|drinking alone|drinking and driving|drinking to fall asleep|escalating alcohol use|tremors|nausea|vomiting|headaches|sweating|anxiety|racing heart|confusion|visual hallucinations|auditory hallucinations|seizures"].[/conditional] [conditional field="opioid" condition="(opioid).is('')"]
Opioid use is [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Reports [checkbox value="no concerning progression of symptoms of opioid use|cravings|urges to use opioids|continued opioid use|use of fentanyl|recent overdose|drowsiness|dizziness|fainting|fatigue|chest pain|difficulty breathing|missing work|irritability|pinpoint pupils|nausea|vomiting|loss of appetite|constipation|diarrhea|stomach cramping|weight loss|racing heart|sweating|chills|palpitations|tearing eyes|yawning|insomnia|bone pain|goose bumps|tremors|leg swelling|yellowing of eyes|loss of libido|confusion|visual hallucinations|auditory hallucinations"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="personality" condition="(personality).is('')"]
[checkbox value="No progression of difficulties with interpersonal relationships, impulsivity, behavioral regulation, or affect regulation|History of|unstable relationships with others|idealizing and devaluing|identity disturbance|feelings of emptiness|affective lability|excessive anger|aggression|efforts to avoid abandonment|impulsive behaviors|suicidality|self injurious behavior|thrill seeking|paranoia|dissociation|attention seeking"].[/conditional] 
[conditional field="anorexia" condition="(anorexia).is('')"][select value="Disordered eating is stable|Disordered eating has improved|Continues to experience disordered eating|Poor control of disordered eating symptoms"]; [checkbox value="restriction of food intake leading to weight loss| failure to gain weight with significantly low body weight that is expected for age, sex, height|fear of becoming fat|fear of gaining weight|distorted view of self, condition"].[/conditional]

[conditional field="bulimia" condition="(bulimia).is('')"][select value="Disordered eating is stable|Disordered eating has improved|Continues to experience disordered eating|Poor control of disordered eating symptoms"]; [checkbox value="eating in a discrete period of time an amount of food this is definitely larger than most people would eat during similar circumstances|recurrent compensatory behavior to prevent weight gain|drinking excessive amount of water or non-caloric beverages|Use of laxatives|Use of diuretics|Use of enemas|fasting|excessive exercise|repeated binges at least 1xweek for at least 3 months|self evaluation is mainly influenced by body shape and weight|forceful vomiting after binge eating|forceful purging after binge eating|fear of eating in public places with others|stealing or hoarding food"].[/conditional]

[conditional field="IED" condition="(IED).is('')"][select value="Behavioral outbursts have improved|There are no notable changes in IED symptoms|IED symptoms are reportedly worse"]; [checkbox value="denying verbal/physical aggression toward person/property/animals, damage/destruction to property, physical assault/injury|verbal aggression|physical aggression|toward|others|property|animals|damage/destruction to property|physical assault/injury"].[/conditional]
[conditional field="schizoaffective" condition="(schizoaffective).is('')"][select value="Affective, psychotic symptoms are stable|Affective, psychotic symptoms have improved|Affective, psychotic symptoms are unchanged|Affective, psychotic symptoms are worse"]; [checkbox value="delusional ideation|thought disorder|bizarre behavior| anhedonia|amotivation|social isolation|flat affect|auditory hallucinations|visual hallucinations|tactile hallucinations|olfactory hallucinations|gustatory hallucinations|perceptual disturbances|persecutory delusions|grandiose delusions|nihilistic delusions|religious delusions|somatic delusions|thought control|thought insertion|thought withdrawal|incongruent affect|circumstantiality|tangential thinking|verbigeration|perseveration|word salad|asociality|avolition|affective blunting|alogia"].[/conditional]
[conditional field="schizophrenia" condition="(schizophrenia).is('')"][select value="Schizophrenia symptoms are stable|Schizophrenia symptoms have improved|Schizophrenia symptoms are unchanged|Schizophrenia symptoms are worse"]; [checkbox value="delusional ideation|thought disorder|bizarre behavior| anhedonia|amotivation|social isolation|flat affect|auditory hallucinations|visual hallucinations|tactile hallucinations|olfactory hallucinations|gustatory hallucinations|perceptual disturbances|persecutory delusions|grandiose delusions|nihilistic delusions|religious delusions|somatic delusions|thought control|thought insertion|thought withdrawal|incongruent affect|circumstantiality|tangential thinking|verbigeration|perseveration|word salad|asociality|avolition|affective blunting|alogia|catatonic behavior"].[/conditional]
[textarea memo="Additional information" rows="1"]
[textarea memo="Additional information" rows="3"] Sleep [select name="variable_25" value="is good|is fair|has improved|is worse"], averaging [text] hours per night; [select value="no difficulties initiating or maintaining sleep, nightmares/night terrors|difficulty initiating sleep|difficulty maintaining sleep|early morning awakening|difficulty returning to sleep|nightmares/night terrors|hypnogogic hallucintations|hypnopompic hallucinations|sleepwalking|daytime sedation|broken sleep, but is able to return to sleep with ease|broken sleep with prolonged difficulty resuming sleep"]. Energy  is [select name="variable_35" value="good; able to perform usual duties|fair; some fatigue, but no significant impact on usual role performance|poor with negative affect on role performance"]. Appetite is [select name="variable_8" value="good|fair|poor"]; [select name="variable_9" value="no significant changes in weight|recent weight gain|recent weight loss"]. [select name="variable_14" value="Endorses|Some difficulty with"] treatment adherence and [select name="variable_11" value="can|is unable to"] contract for safety. SI/HI: [select name="variable_12" value="Denies active/passive ideation/plan/intent|Endorses passive ideation, but no plan/intent or history of violence/impulsive behavior|Endorses passive ideation with loose plan, but no intent or history of violence/impulsive behavior|Endorses active ideation, but no plan/intent or history of violence/impulsive behavior|Endorses active ideation with loose plan, but no intent or history of violence/impulsive behavior"] [checkbox value="Plans are firm|Plans are vague|Plans are inconsistent|Plans are unviable|Plans are lethal|Plans are nonlethal|Plans are undisclosed"] [checkbox value="No ambivalence about suicide|Endorses/exhibits ambivalence about suicide|intention to die|intention of suicide"] Denies [checkbox value="AH|VH|psychosis|mood lability|obsessions/compulsions|reexperiencing/avoidance/arousal symptoms|side effects"]. 
[checkbox name="safety" memo="safety" value=""]
[conditional field="safety" condition="(safety).is('')"]SAFETY PLAN: Triggers: [text]
Personal warning signs: [text]
Coping strategies: [text]
Protective Factors: [text] [checkbox value="Treatment responsiveness|Connectedness to individuals, family, community, and social institutions|Problem-solving skills|Coping skills|Ability to adapt to change|Sense of purpose or meaning in life| Cultural, religious, or personal beliefs that discourage self-injury|Good social skills|Ability to manage feelings of anger|Good health|Access to mental and physical health care|Healthy fear of risky behaviours and pain|Hope for the future and optimism|Sobriety|Medical compliance|Sense of the importance of health/wellness|Impulse control|Strong sense of self-worth or self-esteem|Sense of personal control or determination|Access to a variety of clinical interventions and support for seeking help|Resiliency|Expressed reasons for living|Being married|Being a parent|Strong relationships, particularly with family members|Opportunities to participate in and contribute to school or community projects and activities|Living in a reasonably safe and stable environment|Having restricted access to lethal means|Sense of responsibility and duty to others|Being a pet owner"]
Social supports: [text]
Securing environment: [text]
Client will call 911 and seek emergency services if aforementioned plans do not improve distress. [textarea memo="Additional information" rows="1"][/conditional]

MENTAL STATUS EXAM: 
APPEARANCE: [select value="Stated age|Older than stated age|Younger than stated age"]. [select value="Well-groomed|Disheveled|Unkempt"]. No acute distress. [select name="c" value="Smooth and coordinated psychomotor movements|Clumsy|Unable to ambulate|Requires wheelchair|Assisted by cane|Assisted by walker"][textarea memo="other" default="" rows="1"].
ORIENTATION: [select value="Oriented to person, place, time, and situation|Unable to assess due to cognitive impairment|"][textarea memo="other" default="" rows="1"].
MOOD: "[text]," assessed as [checkbox value="euthymic|depressed|anxious|angry|irritable|happy|labile"][textarea memo="other" default="" rows="1"].
AFFECT: [checkbox value="Sad|Tearful|Anxious|Flattened|Restricted|Irritable|Happy|Full Range"][textarea memo="other" default="" rows="1"].
SPEECH: [select value="Normal rate/rhythm/tone, spontaneous, unpressured|Pressured|Paucity"][textarea memo="other" default="" rows="1"].
THOUGHT PROCESS: [select value="Logical, Linear, Age appropriate|Circumstantial|Tangential"][textarea memo="other" default="" rows="1"].
ASSOCIATIONS: [select value="Intact|Loose|Tangential|"][textarea memo="other" default="" rows="1"].
THOUGHT CONTENT: [select value="No evidence of delusions/paranoia, response to internal stimuli, or suicidal/homicidal ideation/plan/intent|SI without plan/intent. No evidence of delusions/paranoia, response to internal stimuli.|SI with plan, but no intent. No evidence of delusions/paranoia, response to internal stimuli.|HI without plan, but no intent. No evidence of delusions/paranoia, response to internal stimuli.|HI with plan/intent. No evidence of delusions/paranoia, response to internal stimuli.|Delusions. No suicidal/homicidal ideation/plan/intent.|Paranoia. No suicidal/homicidal ideation/plan/intent."][textarea memo="other" default="" rows="1"].
ATTENTION/CONCENTRATION: [select value="Adequate based on answers to interview questions|Unable to assess due to cognitive impairment|Impaired attention and concentration as evidenced by |"]. [textarea memo="other" default="" rows="1"]
MEMORY: [select value="Recent and remote memories both intact based on answers to interview questions|Unable to assess due to cognitive impairment|"]. [textarea memo="other" default="" rows="1"]
LANGUAGE: [select value="No evidence of aphasia|Unable to assess due to cognitive impairment|"][checkbox value="Able to name objects and repeat phrases"]. [textarea memo="other" default="" rows="1"]
JUDGEMENT: [select value="Good - has realistic expectations of treatment|Fair - has some uncertainty in treatment expectation|Good - has realistic expectations of treatment|Poor - has unrealistic expectations of treatment|Impulsive"][textarea memo="other" default="" rows="1"].
INSIGHT: [select value="Good - accepting of illness, recognizes symptoms/behaviors, and consequences of symptomatic behaviors if left untreated|Fair - accepting of illness, but some difficulty recognizing symptoms/behaviors/consequences|Poor - Unable to accept illness and recognize symptoms/behaviors/consequences"][textarea memo="other" default="" rows="1"].
FUND OF KNOWLEDGE: Intelligence is [select value="average|above average|below average|unable to be assessed due to cognitive impairment"] based on answers to interview questions. [textarea memo="other" default="" rows="1"]

RECOMMENDATIONS/CONSIDERATIONS: The clients' symptoms [checkbox name="Progress" value="have regressed|have made no notable change|are mildly progressing|have stabilized|have made apparent progress|fluctuate related to situational contexts but are overall managed|have made significant improvements|are maintaining past gains and stable|have increased and are difficult to manage"]; thus, [textarea memo="other" default="" rows="1"].

TREATMENT PLAN: 
The client was counseled about safety factors and emergency services, as well as instructed to monitor for worsening of psychiatric symptoms. For suicidal emergencies with intent or severe behavioral and mood changes, the client will call 911 and seek emergency services. 
The client was counseled about a menu of reasonable treatment options both pharmacological and non-pharmacological. Discussed risks vs. benefits, as well as side effects with the client, reviewed alternative treatments, including no treatment, and answered any questions. The client agrees that the benefits outweigh acknowledged risks.
MEDICATIONS: 
An E-FORCSE search was conducted on this visit to examine controlled substance history: [textarea memo="other" default="" rows="1"]
Goals: [checkbox name="Goals" value="Symptom reduction|skill acquisition|improve functioning|improve health|maintain positive gains|reduce ineffective behaviors"]. Projected time for goal attainment: 3-6 months vs. long-term treatment. 
Strengths/Barriers: [checkbox name="StrengthWeakness" value="Expression of willingness to engage in treatment recommendations|positive social supports|well-connected with outpatient supports|history of actively engaging in mental-health treatment|but|current apprehension to engage in psychopharmaceutical intervention|current apprehension to engage in structured psychotherapy|current emotional distress|limited social supports|dysfunctional interpersonal relationships|unemployed"]
Follow up in [text] [checkbox name="time" value="weeks|month|months"] for reassessment, or sooner, as needed.
Supportive psychotherapy will be continued in conjunction with follow-up visits to target the cognitive, behavioral, social, and emotional impact of psychiatric illness.
Collaborate with referral source as needed to obtain records, labs, imaging studies, and serial vital signs.
END TIME: [text]