Immanuel

Date of Service: [date default=timestamp]

PATIENT NAME: [textarea memo="NAME" default="" rows="1"]

CC: [checkbox value="follow up|depression|anxiety|bipolar|mood disorder|psychosis|behavioral"]

Client is a [text name="variable_3" default=""] year old [checkbox name="variable_4" value="Caucasian|African American|Hispanic|Asian|Native American|Biracial"][text name="variable_5" default=" "][comment memo="other"] [checkbox name="variable_6" value="male|female"][textarea memo="other" default="" rows="1"] who presents today for [checkbox name="variable_7" value="new psychiatric evaluation|psychiatric follow up|medication management"][textarea memo="other" default="" rows="1"]. 

Met with patient today and they report [checkbox value="sleeping well|sleeping is fair|sleeping is poor"]. Reports appetite is [checkbox value="good|fair|poor"]. Guest reports their anxiety as [checkbox value="1|2|3|4|5|6|7|8|9|10"]/10, and reports depression as [checkbox value="1|2|3|4|5|6|7|8|9|10"]/10. Reports mood as "[checkbox value="ok|good|fair|poor"]." [checkbox value="No reports of any mood fluctuations by guest or staff."] [checkbox value="Guest was provided support and therapeutic listening to reduce anxiety and depression."] [textarea memo="other" default="" rows="3"]



MENTAL STATUS: 
GENERAL: [checkbox value="Alert|Sleepy"]
ORIENTATION: [checkbox value="Person|Place|Date|Situation|Disoriented"]
EYE CONTACT: [checkbox value="appropriate|good|poor"]
SPEECH: [checkbox value="normal rate, tone, volume|slow rate|rapid speech|low volume|loud volume"]
MEMORY: [checkbox value="Intact|Forgetful|Disoriented"]
CONCENTRATION/COGNITION: [select value="normal|impaired"]
MOOD: [select value="Neutral|Manic|Angry|Depressed|Anxious"]
AFFECT: [select value=Neutral|Appropriate to mood|Blunted|Flat|Labile|irritable|tearful"]
THOUGHT PROCESS: [select value="logical, Goal-Directed|illogical at times|Paranoia| Delusions"]
INSIGHT: [select value="Good|Fail|Poor"]
JUDGMENT: [select value="Good|Fair|Poor"]
HALLUCINATIONS: [checkbox value="Denies|Auditory|Visual|Tactile"]

Patient goals and Strengths: [checkbox value="To walk better|To go home"] [textarea memo="other" default="" rows="1"]

LABS: [checkbox value="Labs Reviewed|none available"] [checkbox value="MED SIDE EFFECTS Reviewed"]

VITALS ARE: [checkbox value="Reviewed|WNL|Abnormal"]

ASSESSMENT: [checkbox value="Guest is tolerating medication.|Medication therapy needs adjustment."]
Assessment of overall level of risk: [select value="low risk of acute dto or dts|high risk of acute dto or dts"]
[checkbox value="Minimal acute risk factors. Several protective factors. Patient reports family and community supports."]
[checkbox value="No labs ordered at this visit. No imaging was requested at this visit. Identified goals and provided support for paient to utilize strengths to accomplish goals. "]

PLAN: 
[select value="Plan is to continue psychiatric medication due to chronicity of symptoms and established diagnosis. Medication continuation is warranted to continue psychiatric stability.| Plan is to taper psychiatric medications once appropriate and symptoms reduced. Recommend therapy and nonpharmacological treatment when appropriate and symptoms have reduced."] 
[checkbox value="Follow up to assess for negative behaviors, medication efficacy, and supportive therapy."]
[checkbox value="Therapy recommendation: Recommended therapy when willing and able."]
[checkbox value=" Staff advised to contact crisis team if dto or dts statements or behaviors and to contact this writer or office."] 
[checkbox value="Provide assessment, therapeutic listening, and medication management to reduce psychiatric symptoms. "]
[checkbox value="Summary of initial treatment target/meds"]
[checkbox value="Offer medication management to treat symptoms. Encourage therapy to address symptoms. Safe and therapeutic milieu."]
[textarea name="variable_1" default=""]