!!IPE

*[textarea memo="Chief compliant" rows="5"]*


History of Presenting Illness:
[var name="name"] [select value="presents today for psychiatric evaluation appointment |initially presented to the emergency department "][select value="alone|with family |with significant other |with DHHS worker |with clinician |by police|"][text memo="names" size="20"][select value=" for psychiatric evaluation and management of | due to reports of |"][text memo="presenting problem" size="20"].  [select value="The patient reports |The family reports |The Guardian reports |The case manager reports |Electronic records indicate |Police report indicates |"][select value="a past history of |no history of mental health concerns until |no history of mental health concerns|"][textarea memo="Mental health history" rows="5"].  [checkbox name="depression" memo="depression" value=""][checkbox name="anxiety" memo="anxiety" value=""][checkbox name="sleep" memo="sleep" value=""][checkbox name="mood" memo="mood" value=""][checkbox name="ptsd" memo="ptsd" value=""][checkbox name="adhd" memo="adhd" value=""][checkbox name="autism" memo="autism" value=""][conditional field="depression" condition="(depression).is('')"]  [var name="name"]'s depression is characterized as [checkbox value="little interest or pleasure in doing things|hopelessness|helplessness|sleeping too much|difficulty getting to sleep|difficulty staying asleep|feeling tired or having little energy|poor appetite|overeating|feelings of inadequacy|irritability|poor concentration|psychomotor retardation|psychomotor agitation|suicidal ideation"].  [select value="Depressive symptoms are present most of the day, nearly every day|Depressive symptoms are mostly present |"][text size="20"][select value=", are exacerbated by |"][text size="20][select value=", are improved by |"][text size="20]. [select value="Depressive symptoms impact|"][select value=" social/work functioning by | "][textarea rows="1"].[textarea memo="Additional Depression information" rows="5"][/conditional][conditional field="anxiety" condition="(anxiety).is('')"]  The patient's anxiety generally presents as [checkbox value="feeling nervous or on edge|worry|difficulty relaxing|feeling restless|difficulty getting to sleep|difficulty staying asleep|irritability|poor appetite|overeating"][text size="20].  [select value="Anxiety is present |"][select value="in the context of multiple different situations/events such as |primarily in social situations such as | "][textarea rows="1"]. [select value="Anxiety usually last for approximately |Anxiety is present most of the time on most days"][text size="20"][select value=", is brought on by |"][text size="20][select value=", is relieved by |"][text size="20]. [textarea memo="Additional Anxiety information" rows="5"][/conditional][conditional field="mood" condition="(mood).is('')"][select value="  Mood instability has been an issue since |"][text size="20"].  [select value="Disordered mood can present as |"][checkbox value="euphoria|excessive energy|excessive self-confidence|insomnia|irritability|agitation|racing thoughts|impulsive behavior|risk taking behavior|paranoia|delusions of grandeur|auditory hallucinations|visual hallucinations|depression|apathy|hopelessness|helplessness|suicidal thoughts|no motivation|hypersomnia"].  [select value="Mood lability is exacerbated by |There are no identified precipitating factors to mood lability|"][textarea rows="1"].  [textarea memo="additional information of mood lability" rows="4"][/conditional][conditional field="autism" condition="(autism).is('')"]
[select value="Per patient,|Per family,|Per record,|"][text size="20"][select value=" they have been | patient has been |"][select value="diagnosed|undiagnosed|"][text size="20"][select value=" autism spectrum disorder "][textarea memo="details of diagnosis/symptom timeframe" rows="4"].  [var name="name"]'s symptoms present as persistent difficulty, in multiple contexts, with social communication and interaction including: [checkbox value="abnormal or failed back and forth conversation|failure to initiate or respond to social interactions|reduced sharing of interests/emotions|limited emotional affect|limited/incongruent nonverbal communication|difficulty with developing/maintaining/understanding relationships|difficulty sharing imaginative play|limited or absent interest in peers"]. They have demonstrated restricted/repetitive patterns of behavior, interests, or activities including: [checkbox value="repetitive motor movements|repetitive speech|infexible adherence to routines|ritualized patterns of verbal or nonverbal behavior|significant difficulty with transitions|rigid thinking patterns|highly restricted and fixated interests|hyper-reactivity to sensory input|hyporeactivity to some sensory input"].  Presentation is [select value="without|with"] intellectual impairment, and [select value="without|with"] language impairment.  [textarea rows="4"][/conditional][conditional field="adhd" condition="(adhd).is('')"]
[var name="name"] has a pattern of [checkbox name=addtype value="inattention and hyperactivity/impulsivity|inattention|hyperactivity/impulsivity"] that interferes with functioning.  [/conditional][conditional field="addtype" condition="(addtype).is('inattention and hyperactivity/impulsivity')||(addtype).is('inattention')"] Inattention manifests as [checkbox memo="At least 6 for ADHD" value="poor attention to details or careless mistakes in work or activities|difficulty sustaining attention|not seeming to listen when spoken to directly|not following through on instructions or failing to finish tasks|having difficulty organizing tasks and activities|avoiding tasks that require sustained mental effort|frequently losing things necessary for tasks|often easily distracted by extraneous stimuli|forgetfulness in daily activities"].[/conditional] [conditional field="addtype" condition="(addtype).is('inattention and hyperactivity/impulsivity')||(addtype).is('hyperactivity/impulsivity')"]  [var name="name"]'s hyperactivity/impulsivity presents as [checkbox memo="six or more for ADHD" value="frequent fidgeting or squirming|often leaving seat when remaining seated is expected|frequently restless|difficulty engaging in leisure activities quietly|often seeming to be on the go or difficult to keep up with|excessive talking|blurting out answers before a question has been completed|difficulty waiting for their turn|interrupting or intruding on others"][/conditional][conditional field="adhd" condition="(adhd).is('')"]
These symptoms have been present since [text memo="before 12yo" size="20"], and are recognized in multiple settings including [text memo="2 or more" size="20"].  [textarea rows="3"][/conditional]
[conditional field="sleep" condition="(sleep).is('')"]Sleep is reported to be generally [select name="sleepq" value="poor |fair |good.|erratic |inconsistent |excessive|"][select value="with difficulty initiating sleep and staying asleep due to |with difficulty initiating sleep due to |with difficulty maintaining sleep due to |"][textarea rows="2"].  They estimate getting approximately [text size="4"] hours of [select value="broken |solid |"]sleep per night.  [select value="Disturbed sleep has been an issue for |Disturbed sleep is a new issue within the last |"][textarea rows="1"].  [select value="There has been no workup for Sleep Apnea|There was a past workup for sleep apnea which indicated |"][textarea rows="1"].  [select value="Current attempts at improving sleep include |The patient is currently attempting no interventions to improve sleep|Current quality of sleep is dependent on |"][textarea rows="2"].  [select value="Past unsuccessful attempts at improving sleep include |There have been no past attempts at improving sleep|"][textarea rows="2"].[/conditional][conditional field="sleep" condition="(sleep).isNot('')"]Sleep is reported to be generally good.  [/conditional][conditional field="depression" condition="(depression).isNot('')"]They deny any marked issues with depression.  [/conditional][conditional field="anxiety" condition="(anxiety).isNot('')"]They deny any significant issues with anxiety.  [/conditional][conditional field="mood" condition="(mood).isNot('')"] Denies a history of mania, excessive mood lability, grandiosity, or uncharacteristic risk taking behavior.  [/conditional]

[select value="Current psychiatric medications include: |Client is unable to recall current psychiatric medications|Unable to cover current psychiatric medications with client due to symptomatic presentation|"][textarea rows="4"].  [select value="Denies current suicidal ideation or thoughts of self harm|Reorts positive for |Denies suicidal ideation but state having thoughts of being better off dead"][textarea rows="1"].  [checkbox value="able to contract for safety.|Denies being able to contract for safety."][textarea rows="1"]  [select value="Denies having access to firearms| reports positive for having guns in the home |"][textarea rows="1"].  [checkbox value=" Explained that we ask this question because guns in the home increase the risk of suicide, homicide and accidental death, Provided education about the importance of keeping guns locked and separated from ammunition. Explained that should this provider feel that patient is unsafe to self or others, provider and patient will work together to develop a safe place to keep weapons to decrease risk of impulsive suicide or homicide."]

PSYCHIATRIC HISTORY:
[select value="Previous psychiatric medication trials include but may not be limited to: |The patient has no history of taking psychiatric medications|We were unable to cover previous psychiatric medication trials due to symptomatic presentation|The patient is unable to recall past psychiatric medication trials|"][textarea rows="1"].  [select value="There is no history of psychiatric hospitalizations|They have been psychiatrically hospitalized |"][textarea rows="2"]. [select value="Previous psychiatric/counseling services includes |They have no history of psychiatric/counseling|History of psychotherapy/counseling was not addressed due to symptomatic presentation|"][textarea rows="2"]. [select value="They deny history of diagnosis/treatment for an eating disorder|They report positive for a history of diagnosis/treatment for an eating disorder including |Unable to assess for history of diagnosis/treatment of an eating disorder due to symptomatic presentation|History of diagnosis/treatment of an eating disorder was not assessed in this encounter|"][textarea rows="1"].[select value="They have no history of thoughts of self-harm|History of thoughts of self harm include |"][textarea rows="2"].  [select value="They have no history of attempting to hurt themself|History of self-harm includes |Unable to obtain history of self-harm due to symptomatic presentation"][textarea rows="2"].  [select value="They have no history of head injuries or traumatic brain injuries|They have a past history of traumatic brain injuries resulting from |They have an underlying cognitive impairment from |"][textarea rows="2"].  [select value="There is no history of trauma|They report having a history of trauma but did not want to elaborate|They report past traumatic experiences to include |Trauma history was not covered due to symptomatic presentation|"][textarea rows="2"].  [select value="They report positive for tobacco use consuming approximately |They report a past history of tobacco but quit approximately |They deny any tobacco use|"][textarea rows="1"].  [select value="They report positive for alcohol use consuming approximately |They report a history abuse quitting approximately |They deny any alcohol use|"][textarea rows="2"].  [select value="They deny a history of recreational substance use|They report utilizing cannabis approximately |They have a history of opiate use disorder |They report utilizing opiates recreationally in the form of |Substance use history was not covered due to symptomatic presentation|"][textarea rows="4"].

Sub use:
Last use of Cannabis: [text name="variable_1" default=" "];
Methamphetamines: [text name="variable_1" default=" "];
Cocaine: [text name="variable_1" default=" "];
Heroin: [text name="variable_1" default=" "];
EcStasy: [text name="variable_1" default=" "];
Tobacco: [text name="variable_1" default=" "];
ETOH: [text name="variable_1" default=" "];

SOCIAL HISTORY:
[var name="name"] identifies [checkbox value="having no one as|significant other|extended family|children|friends|church members"][textarea rows="1"] social-support network.  They have [select value="0|1|2|3|4|5|6|7|"][textarea rows="1"] children.  Their level of education is [select value="highschool|an undergraduate degree in |a graduate degree in |some highschool|some college|currently in grade school|currently in highschool|currently in college studying |currently in graduate school studying |"][textarea rows="1"].  They are [select value="currently on disability due to their mental health condition|currently on disability due to their medical condition|currently employed |currently retired from |"][textarea rows="1"].  Financially they [select value="have no immediate concerns|are burdened by healthcare costs|have concerns related to supporting their family|"][textarea rows="1"].  Their source of income is primarily [select value="disability|social security|unemployment|current employment|family support|"][textarea rows="1"].  They have [select value="no current housing concerns|a currently unstable housing situation related to |"][textarea rows="1"].  [select value="Spirituality was not addressed this visit|Spirituality is identified as |"][select value="|Christian|Catholic|Muslim|Jewish|Spiritual but not practicing|Athiest|Agnostic|"][textarea rows="1"].  Sexual orientation [select value="was not addressed this visit|is identified as |"][select value="|heterosexual|homosexual|bisexual|pansexual|asexual"][textarea rows="1"].  [select value="They have no military history|Military history includes |Military history was not addressed this visit|"][textarea rows="1"].  [select value="They have no current legal concerns|Legal concerns include |Legal concerns were not addressed due to symptomatic presentation"][textarea rows="1"].

ASSESSMENT
Patient is currently displaying [select value="symptoms of|well managed|moderately managed|poorly managed"] [checkbox value="depression|anxiety|sleep disturbance|psychosis|substance use disorder|cognitive impairment|impulsivity|mood lability|alcohol dependence|opioid dependence|autism spectrum disorder"][textarea memo="other" default="" rows="1"] which is [select value="likely caused by|likely exacerbated by|likely the result of"] [checkbox value="their substance use disorder|their trauma history|their depressive disorder|their anxiety disorder|their bipolar disorder|interpersonal/family conflict|the stressors of a rigorous substance use program|maladaptive behaviors|poor psychosocial support systems"][textarea memo="other" default="" rows="1"]. Patient would benefit from [checkbox value="continued psychopharmaceutical intervention|adjustments to current psychopharmaceutical intervention|continuation of current psychotherapy|engaging in grief therapy|engaging in CBT|engaging in family therapy|enhanced psychosocial supports|increasing personal time and self-care"][textarea memo="other" rows="1"]. Prognosis is [select value="good|fair|poor"] considering the patient [select value="remains adherent to|actively engages in|is not currently responding to"] medication/therapy to address [textarea memo="target of treatment" rows="1"][checkbox value=" and whether they are able to engage constructively with social supports"]. [checkbox value="Barriers to success include: "][checkbox value="current apprehension to engage in psychotropic intervention|current apprehension to engage in structured substance use treatment|current emotional distress due to unresolved trauma|limited social supports|dysfunctional interpersonal relationships|poor insight"][textarea memo="barriers" rows="1"]. [checkbox value="Patient strength for success include: "][checkbox value="expression of willingness to engage in treatment recommendations|positive social supports|are well connected with outpatient supports|history of actively engaging in mental-health treatment|high intelligence"][textarea memo="strengths" rows="1"].  [textarea rows="5"]