IKARE HPI – 22 JUN 1131

History was provided by the [select name="variable_1" value="patient|guardian"].

Patient presented on [date name="variable_25" default="06/16/2021"] to clinic via [select name="variable_2" value="telephone|video|in person visit"].

Pt is a [text name="variable_3" default="AGE"] year old [select name="variable_4" value="male|female"] with a history of [text name="variable_5" default="diagnosis history"] reporting [select name="variable_6" value="worsening|improvement of|no change in"] symptoms of [text name="variable_7" default="describe symptoms"]. Patent reported [textarea name="variable_8" default="THE CONVERSATION WITH THE PATIENT"] Pt reported symptoms of [text name="variable_9" default="describe symptoms"] which include [textarea name="variable_10" default="HOW ARE THE SYMPTOMS MANIFESTING"]. Pt reported energy is [select name="variable_11" value="normal|high|low"]. Pt [select name="variable_12" value="accepted|declined|continued"] individual therapy to help cope with [textarea name="variable_13" default="sample text"]. Pt reported [text name="variable_14" default="sample text"] hours of [text name="variable_15" default="sample text"] sleep a night and wakes feeling [select name="variable_16" value="refreshed|not refreshed"]. Pt OTC medications [textarea name="variable_17" default="sample text"]. Pt reported [select name="variable_18" value="good|poor"] appetite eating [text name="variable_19" default="sample text"] meals daily. Pt reports height [text name="variable_20" default="sample text"] and weight [text name="variable_21" default="sample text"]lbs. Pt reports coping with [text name="variable_7" default="describe symptoms"] by [text name="variable_22" default="describe symptoms"]. Pt reports mood is [text name="variable_23" default="describe symptoms"]. Pt [text name="variable_24" default="SI STATEMENT"].

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Assessment

Patient agrees to treatment plan. Ellipsas reviewed and patient was consulted on the results of the screening. Supportive psychotherapy provided and Texas PMP website reviewed.

Pt is a [text name="variable_3" default="AGE"] year old [select name="variable_4" value="male|female"] with a history of [text name="variable_5" default="diagnosis history"] presenting for follow-up today. There is [select name="variable_25" value="evidence|some evidence|no evidence"] of [text name="variable_5" default="diagnosis history"] today. Patient endorses [textarea name="variable_26" default="sxs on meds"] with the addition of [textarea name="variable_27" default="list the meds"]. At this time [select name="variable_28" value="will continue medications|change medications"]. [select name="variable_29" value="Medication refills provided|No refills provided"]. [select name="variable_30" value="Labs ordered|No labs ordered"]. Will need to review [textarea name="variable_31" default="LABS OR THINGS TO REVIEW NEXT TIME"] next visit. Ellipsas and PMP were reviewed, assessed, and uploaded.