Follow-up Visit#1

CC: Follow up visit for [checkbox value="depression|anxiety|insomnia|inattention|bipolar disorder|mood disorder|mood lability|irritability|agitation|borderline personality disorder|suicidal ideation|schizoaffective disorder|autism spectrum disorder"][text]. 

Patient was last seen [select value="in this office|in this office by |by televisit |by televisit with "] [text] 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=""][checkbox memo="mood disorder" name="mood" value=""][conditional field="anxiety" condition="(anxiety).is('')"][/conditional][conditional field="dep" condition="(dep).is('')"]Depression 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|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea]. Depression is reported to be present [select value="occasionally|almost never|about 50% of the time|most of the time on most days|almost always|"][text]. 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|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 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]. 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('')"]

Mood disorder 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]. They report [checkbox value="depression|anxiety|irritability|mania|hypomania|impulsivity|emotional lability|"][text] 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]

[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]
[comment memo="Adapted from original work by "][link url="https://www.soapnote.org/author/chasecardurns/" memo="chasecardurns"][comment memo=" at "][link url="https://www.soapnote.org/mental-health/f-u-hpi-2/" memo="https://www.soapnote.org/mental-health/f-u-hpi-2/"]
[comment memo="Cardurns C. F/U HPI. ​​The SOAPnote Project. https://www.soapnote.org/mental-health/f-u-hpi-2/. Published April 20, 2020. Accessed June 30, 2020."]


Medical Decision Making:
OSH (outside hospital) records reviewed and shows…” 
“Records from previous hospitalization(s) reveal….”- 
[checklist name="Records" value="EMS report|TN CSMD profile|external pharmacy records|records from outside hospital|outpatient records|records from past admissions"]
Relevant findings from any review of old records or from any additional history you obtain – or a note to the effect that you carried out such a review but found no additional relevant information. “Old records reviewed” or “additional history obtained from family” is not enough. You need to give relevant findings or say explicitly that there were none.