Joey1 symptoms

HISTORY OF PRESENTING PROBLEM[comment memo="
99212 requires 1 HPI
99213 requires 1 HPI + pertinent ROS
99214 requires 4 HPI + pertinent ROS plus one other + 1 P/F/S hx
99215 requires 4 HPI + complete ROS + 2 P/F/S hx"]

*Chief Complaint*
Date and Time of Service:[date default="today"] [text size="8"]
Patient is see in this intake for [checkbox value="depression|anxiety|psychosis|substance abuse|cognitive impairment|impulsivity|mood lability|sleep disturbance|alcohol dependence|opiate dependence|symptoms of depressed mood


|symptoms of depressed mood|symptoms of anxiety and internal thought process|poor impulse control|mood lability|Difficulty waiting or delaying gratification|sleep disturbance|obsessive thoughts/compulsions|mood swings|visual hallucinations|auditory hallucinations|Difficulty waiting or delaying gratification|recent trauma|difficulty managing emotional reactions|interpersonal or family conflict|
| Feelings of guilt such as sudden anger or frustration| in inappropriate situations| |Increased anxiety in social situations| Difficulty shifting attention| 
| Increased stress in response to changes|
| increased feelings of sadness|  anxious|  empty mood|  Feelings of hopelessness or worthlessness |  Loss of interest or pleasure in activities|  Fatigue or loss of energy|  Changes in appetite and/or  |Sleeping too much or too little| 
|  Difficulty concentrating| remembering| or making decisions| 
|  Thoughts of death or suicide| or suicide attempts| autism spectrum disorder| 
| Difficulty concentrating|  remembering or making decisions|  Insomnia|
| early-morning wakefulness| 
| oversleeping|  
| Appetite and/or weight changes|  
| Thoughts of death or suicide|  
| Restlessness or irritability|  
| Excessive worry or feeling overwhelmed by stress| 
| Restlessness or feeling on edge|  
| Difficulty controlling worry or fear|  
| Muscle tension|  
| Sleep disturbances (difficulty falling or staying asleep)|  
| Irritability| Fatigue|  
| Difficulty concentrating or mind going blank|  
| Increased heart rate|  
| Avoiding situations due to anxiety|  
| Difficulty falling asleep at night|  
| Waking up during the nigh|  
| Waking up too early and not being able to fall back asleep
|  Not feeling well-rested after a night's sleep|  
| Daytime tiredness or sleepiness|  
| Irritability| depression| 
| or anxiety|  
| Difficulty paying attention| 
| focusing on tasks| or remembering|  
| Increased errors or accidents|  
| Ongoing worries about sleep|  
| Frequent yawning| 
| Mood changes| 
| Decreased motivation or energy|  
| Increased mistakes or accidents|  
| Concerns about not getting enough sleep| 
| autism spectrum disorder | 
| Difficulty adhering to rules or guidelines| 
| Engaging in risky behaviors | 
| Difficulty managing emotional responses| 
| Challenges with emotional and behavioral regulatiocognitive impairment| 
| Difficulty waiting or delaying gratificatio| 
| Acting impulsively without considering consequences| 
| Increased anxiety in social situations| 
| Difficulty shifting attention| 
| Increased stress in response to changes|  
| Auditory    Hallucinations| 
| Visual    Hallunications| 
|Delusional    Thought    Process| 



| Thoughts of death or suicide|or suicide attempts|autism spectrum disorder"] [textarea memo="other" default="" rows="1"]
[textarea memo="quotes" default="" rows="1"]

*Interval History*
The patient continues to report the following symptoms[comment memo="SYMPTOM"][checkbox value="depressed|anxious|aggressive|impulsive|inattentive|irritable|withdrawn|unable to sleep|delusional|auditory hallucinations|visual hallucinations"][textarea memo="other" default="" rows="1"].
Which is described as[comment memo="SEVERITY "][checkbox value=" the same as it has been| better| somewhat worse than it has been| significantly worse than it has been"][textarea memo="other" default="" rows="1"]
The patient notices that it is sometimes improved by [comment memo="Modifying factors "][checkbox value="talking to someone|being alone|doing something physical like walking|doing something that is distracting"][textarea memo="other" default="" rows="1"]


*Review of Systems* [comment memo="Include for 99213 thru 99215"]
The patient identifies the following symptoms: [comment memo="Pertinent System "][checkbox value="irritability|mood instability|heightened anxiety|attention problems|troubled by hallucinations|fearfulness|nightmares|alcohol cravings|opiate cravings"][textarea memo="other" default="" rows="1"]
Other systems:
Neurological - [checkbox value="Headaches|weakness|disturbed sleep|denied"][textarea memo="other" default="" rows="1"]
GI - [checkbox value="Upset stomach|nausea|constipation|heatburn|denied"][textarea memo="other" default="" rows="1"]
All other systems negative

*Past/Family/Social History* [comment memo="Include for 99214 + 99215"]
[textarea rows="3"]


REVIEW/MANAGEMENT
*Problem Status*[comment memo="
Problem status: Established-stable/improved=1pt each 
Established-worsening=2pt each 
New problem, no additional workup planned=3pt (only one) 
New problem, additional workup planned=4pt"]
The patient's psychiatric review of symptoms can best be characterized as: [checkbox value="minimal|patient is resistant|patient is making some progress|patient is working on goals, but remains symptomatic"][textarea memo="other" default="" rows="1"]

*Data Reviewed*
[comment memo="1pt each, 2pt for summary"][checkbox value="I reviewed the chart (ECW):"][textarea default="" rows="1"][comment memo="
1pt each, 2pts for summary"][checkbox value=" I reviewed the following labs, imaging, consults: "][textarea default="" rows="1"][comment memo="
1pt each, 2pts for summary"][checkbox value=" I obtained collateral information from "][textarea default="" rows="1"][comment memo="
2pts each"][checkbox value=" I consulted with "][textarea memo="individual and reason for consultation" default="" rows="1"][checkbox value="I reviewed PMP|and found no abnormal results.|and found abnormal results "][textarea default="" rows="1"]

*Management*[comment memo="
Risk/Morbidity/Mortality
Low (99213)= One stable chronic illness/Two or more slef-limited or minor problems
Moderate (99214)= Prescription meds; chronic illness with mild exacerbation or side effects of treatment; 2 or more stable chronic illnesses
High (99215)= Psychiatric illness with potential threat to self or others, drug therapy requiring intensive monitoring for toxicity; one or more chronic illnesses with severe exacerbation, progression, or side effects of treatment"]
The following interventions were ordered/recommended this appointment:
[textarea rows="5"] [checkbox value="I discussed risks vs. benefits, as well as side effects with the patient, reviewed alternative treatments, including no treatment, and answered any questions. "][checkbox value="Medications have been discussed with parents or legal guardians. "][checkbox value="The patient and/or parent or legal guardian received medication information in the form of a medication information handout. "]

Medication List:
[textarea rows="5"]


ASSESSMENT
Patient is currently displaying [select value="symptoms of|well managed|moderately managed|poorly managed"] [checkbox value="depression|anxiety|sleep disturbance|psychosis|substance abuse|cognitive impairment|impulsivity|mood lability|alcohol dependence|opiate 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 cancer diagnosis|their cancer treatment|their unmanaged depressive disorder|their unmanaged anxiety disorder|their unmanaged bipolar disorder|interpersonal/family conflict|current psychopharmaceutical intervention|current psychotherapy|current 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 psychopharmaceutical intervention|current apprehension to engage in structured psychotherapy|current emotional distress of recent cancer diagnosis|limited social supports|dysfunctional interpersonal relationships"][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"][textarea memo="strengths" rows="1"].  [textarea rows="5"]


PLAN:
[textarea rows="5"]

I, Joseph Weaver, DNP PMHNP-BC, personally examined the client obtained a history, conducted a mental status examination of the patient, and developed the plan of care.