Initial Note

COMMON GROUND  

Date and Time of Service: [date default=timestamp]
Cheif Complaint:
[textarea name="variable_97" default="" rows=3] 

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"] 

Client reports a hx of:
[textarea memo="Past Dx, who diagnosed" name="variable_24" default=" " rows="3"]
[textarea memo="Interval Hx, Onset, duration" default=" " rows="8"]
[textarea memo="Current Psychiatric Medication" name="variable_14" default="Current medications " rows="3"] 
[textarea memo="Past Psychiatric Medications" name="variable_99" default="Previous medications treatment included " rows="3"][textarea memo="Tx response" default=" " rows="6"]
Medication Compliance: [checkbox name="variable_98" value="Compliant|Non-compliant"]

Client presents with the following symptoms:
[checkbox value="agitation"][checkbox name="variable_8" value=" depressed mood|loss of interest/pleasure|weight loss|weight gain|insomnia| hypersomnia|psychomotor retardation|psychomotor agitation|fatigue|feelings of worthlessness/excessive or inappropriate guilt|decreased concentration/indecisiveness|thoughts of death/suicide|excessive anxiety and worry|finds it difficult to control the worry|anxiety and worry are associated with restlessness or feeling keyed up or on edge|being easily fatigued|dificulty concentrating or mind going blank|irritability|muscle tension|sleep disturbance"] [textarea name="variable_9" default="" rows="1"][comment memo="other"] [textarea memo="Previous symptoms" default="" rows="2"] [textarea memo="Onset" default="" rows="2"] [textarea memo="Location" default="" rows="2"] [textarea memo="Duration of symp" default="" rows="2"] [textarea memo="Characteristics" default="" rows="2"] [textarea memo="Aggravating factors" default="" rows="2"] [textarea memo="Relieving factors" default="" rows="2"] [textarea memo="Timing" default="" rows="2"] [textarea memo="severity" default="Today, client rates depression /10, anxiety /10, stress /10, and describes appetite as __poor __fair __good, sleep as __poor __fair __good." rows="4"]

The client reports the symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning:
[checkbox value="" rows="3"] [checkbox value="Client denies any "][checkbox name="variable_15" value="auditory hallucination|visual hallucinations|racing thoughts|excessive worry|suicidal ideation|homicidal ideation|thoughts of self-harm or self-injury|thoughts of harm to others"] [textarea name="variable_28" default=" " rows="1"]

PAST PSYCHIATRIC HISTORY
[checkbox value="Psychiatric history obtained by record"] [textarea memo="medication trials / as noted in HPI" default="" rows="4"] [checkbox value="Client denies any previous history of"][checkbox value=" psychiatric diagnosis|psychiatric care|hospitalization|outpatient treatment|past suicide attempts|self-injury|violent behavior to others"] [checkbox value="Denies taking any previous psychiatric medications." comment memo="denies med trial"]

SUBSTANCE USE/ ADDICTIVE BEHAVIORS
[checkbox value="Declines to answer"][textarea memo="qty,frequency,last drink, past tx" default="" rows="2"] [checkbox value="Denies using nicotine or tobacco products|Denies any alcohol use|Denies using illicit drugs.|Denies using|stimulants|opiates|marijuana|hallucinogens|synthetics|bath salts|club drugs."] [checkbox value="Denies any addictive behaviors such as eating, spending, gaming, gambling, or sexual addictions."]

FAMILY PSYCHIATRIC HISTORY:
[checkbox value="unknown"] [textarea memo="biological, adopted?, unknown?, med trial" default="" rows="2"] [checkbox value="Client denies any family history of"] [checkbox value=" mental health disorders|suicide attempts|completed suicide by any other family members."]

MEDICAL HISTORY: [textarea memo="" default="" rows="2"] [checkbox value="Client denies any history of|client endorses history of"][checkbox value="cardiac|respiratory|endocrine|neurological|head injury|HIV|hepatitis|Denies any surgical history."]

CURRENT MEDICATIONS:  [textarea memo="Current med list" default=" " rows="2"] [checkbox value=" Denies taking any other medications|Denies taking herbals or supplements|Denies OTC meds"]

ALLERGIES: [textarea memo="meds/food" default="" rows="2"] [checkbox value="Denies any medication allergies.|Denies any food allergies."]

PSYCHOSOCIAL:
[checkbox name="variable_22" value="single|married|separated|divorced|in a relationship|widowed|a widower|no children.|1 child.|has children and actively parenting.|has children, not actively parenting.|has grown children."] [checkbox name="variable_17" value="Lives alone.|Lives with partner.|Lives w/ roommates.|Lives with parents.|Currently homeless."] [textarea memo="Lives with other" name="variable_26" default="" rows="1"] 
EDUCATION:
[checkbox name="variable_18" value="No formal education|Elementary school completed|Some highschool-did not graduate|High school graduate|GED|Vocational program completed|College graduate"][textarea memo=" " default="" rows="1"]
EMPLOYMENT:
[checkbox name="variable_19" value="Unemployed|Employed|on Disability|on Social Security|Reports being financially independent."][textarea memo="job title" name="variable_27" default=" " rows="1"][textarea memo="comments" default="" rows="1"] 
RELIGIOUS/SPIRITUAL:
[checkbox value="Denies current involvement in church or other religious or spiritual organizations.|Currently involved in church or other spiritual organization."] 
FAMILY:
[textarea memo="Client was raised by , birth order, developmental, Client reports having a good relationship with , Denies any developmental delay." default="" rows="4"] 
LEGAL / MILITARY
[checkbox name="variable_20" value="Denies any current legal issues or pending charges|Client is on probation|Client is on parole|Client has pending charges|"][textarea memo="which county? ROI?" default="" rows="1"] [checkbox name="variable_21" value="Denies any previous military experience|Client has military experience|Client is a veteran"]

(OBJECTIVE)

MENTAL STATUS EXAM: 
Appearance: [select value="stated age|older than stated age|younger than stated age"], [select value="neat|disheveled"][textarea memo="other" default="" rows="1"].
Gait and Station / Muscle Strength and Tone: [select name="c" value="Steady gait while walking, normal strength bilaterally|"][conditional field="c" condition="(c).is('')"]
[checkbox value="steady gait while walking|unsteady gait while walking|clumsy|unable to ambulate|in bed|in wheelchair|assisted by cane|assisted by walker|rigid|spastic|normal strength bilaterally|weakness noted in "][/conditional][textarea memo="other" default="" rows="1"].
Mood and Affect:
Mood- [checkbox value="euthymic|depressed|anxious|angry|irritable|happy|fluctuating"][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 and rhythm, not pressured|pressured|paucity"][textarea memo="other" default="" rows="1"].
Thought process: [select value="logical, linear, age appropriate|circumstantial|"][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, |"][select value="no evidence of response to internal stimuli, |"][select value="no suicidal ideation or intentions, |"][select value="no homicidal ideation or intentions|"][textarea memo="other" default="" rows="1"].
Orientation: [select value="Oriented to person, place, and time|unable to assess due to cognitive impairment|"][textarea memo="other" default="" rows="1"].
Attention and Concentration: [select value="Adequate attention and concentration 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 patient's 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|able to repeat phrases"] [textarea memo="other" default="" rows="1"]
Judgment and Insight:
Judgment- [select value="fair|good|poor|impulsive"][textarea memo="other" default="" rows="1"].
Insight- [select value="fair|good|poor"][textarea memo="other" default="" rows="1"]
Fund of Knowledge: Based on the answers to interview questions, patient's intelligence is judged to be [select value="average|above average|below average|unable to assess due to cognitive impairment"][textarea memo="other" default="" rows="1"]


[textarea memo="DATA REVIEWED: " default=" " rows="1"][checkbox value="I have reviewed the following "][checkbox value="previous records|intake records|transfer records|labs|imaging|referral records"] [textarea default="" rows="1"][comment memo="I obtained collateral information from|family member|staff. I consulted with medical director"]
[checkbox value=" I reviewed PDMP|No report found in client's name.|no concerns.|and found abnormal results."][textarea default="" rows="2"]

Medications Dispensed at This Visit:
[textarea name="variable_93" default="" rows="3"]

Patients Preferences: [textarea name="variable_91" default="CRU" rows="2"]

Recovery Based Language: [checkbox name="variable_95" value="precontemplation|contemplation|maintenance|action|preperation"]

Guardianship:
[checkbox name="variable_89" value="patient does not have a guardian|patient has a guardian"] 
Guardian Contact:[textarea name="variable_87" default="" rows"2"]

ASSESSMENT:
 [checkbox value="Client meets DSM-5 Criteria for |Diagnostic Impression: "][textarea memo="other" default="" rows="5"]

PLAN: [textarea memo="meds, psychotherapy, black-box warning" default="Client was educated on the recommendation for treatment, including the following: " rows="8"]
[checkbox value="Client was counseled on benefits, risks, side effects, reviewed alternative treatments, including no treatment, and answered all client questions. "] [checkbox value="Client counseled to notify the clinic/provider of any side effects, adverse reaction, changes in thought, or worsening mood, SI/HI/DTS/DTO, go to ER, or call 911, or crisis hotline."] [checkbox value="Client verbalizes understanding and agrees with the treatment plan."] [checkbox value="The client and/or parent or legal guardian received medication information in the form of a medication information handout."] [checkbox value="Medications have been discussed with parents or legal guardians. "]
COMMON GROUND

Date and Time of Service:
Cheif Complaint:


Client is a year old other other

Client reports a hx of:
Past Dx, who diagnosed
Interval Hx, Onset, duration
Current Psychiatric Medication
Past Psychiatric MedicationsTx response
Medication Compliance:

Client presents with the following symptoms:
other Previous symptoms Onset Location Duration of symp Characteristics Aggravating factors Relieving factors Timing severity

The client reports the symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning:


PAST PSYCHIATRIC HISTORY
medication trials / as noted in HPI denies med trial

SUBSTANCE USE/ ADDICTIVE BEHAVIORS
qty,frequency,last drink, past tx

FAMILY PSYCHIATRIC HISTORY:
biological, adopted?, unknown?, med trial

MEDICAL HISTORY:

CURRENT MEDICATIONS: Current med list

ALLERGIES: meds/food

PSYCHOSOCIAL:
Lives with other
EDUCATION:

EMPLOYMENT:
job titlecomments
RELIGIOUS/SPIRITUAL:

FAMILY:
Client was raised by , birth order, developmental, Client reports having a good relationship with , Denies any developmental delay.
LEGAL / MILITARY
which county? ROI?

(OBJECTIVE)

MENTAL STATUS EXAM:
Appearance: , other.
Gait and Station / Muscle Strength and Tone: other.
Mood and Affect:
Mood- other.
Affect- other.
Speech: other.
Thought process: other.
Associations: other.
Thought Content: other.
Orientation: other.
Attention and Concentration: other
Memory: other
Language: other
Judgment and Insight:
Judgment- other.
Insight- other
Fund of Knowledge: Based on the answers to interview questions, patient's intelligence is judged to be other


DATA REVIEWED: I obtained collateral information from|family member|staff. I consulted with medical director


Medications Dispensed at This Visit:


Patients Preferences:

Recovery Based Language:

Guardianship:

Guardian Contact:

ASSESSMENT:
other

PLAN: meds, psychotherapy, black-box warning

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.53, 121 form elements, 134 boilerplate words, 2 text boxes, 53 text areas, 1 dates, 44 checkboxes, 17 drop downs, 3 comments, 1 conditionals, 250 total clicks
Questions/General site feedback

Send Feedback for this SOAPnote

This site uses Akismet to reduce spam. Learn how your comment data is processed.

More SOAPnotes by this Author: