Keife Intial

Date: [date name="variable_1_date" default=""]
Time: [text name="variable_1_time" default=" "]

[text name="name" memo="Patient name" size="20"] is a [text memo="age" size="2"]-year-old, [text memo="ethnicity" size="20"],[checkbox value="single|married|divorced|partnered"][checkbox value="cis-gender female|cis-gender male|transgender female|transgender male|gender non-binary individual"][text memo="other gender" value="20"]
History of Presenting Illness:
[var name="name"] that [select value="presents via telehealth|presents in this outpatient appointment "][select value="alone|with family |with significant other "][text memo="names" size="20"][select value=" for evaluation and management of | due to reports of |"][checkbox value="depression|anxiety|cognitive impairment|impulsivity|mood lability|sleep disturbance"] [textarea memo="other" default="" rows="1"].[text memo="presenting problem" size="20"]. [select value="The patient 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="2"].

HISTORY OF PRESENT ILLNESS:
Age of symptom onset[text name="variable_5" default=" "]

Current symptoms and current functional impairments across settings[select name="variable_7" value="Home|Work|School|Church|Social Settings"]

Scales and Screening:
ASRS: [select value="unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
PHQ-9: [select value="unable to assess|declined|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
GAD-7: [select value="unable to assess|declined|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]


PSYCHIATRIC REVIEW OF SYSTEMS:
ADHD:

Patient ENDORSES [text name="variable_9" default=""] # out of 9 inattentive symptoms of ADHD as occurring often or very often, including[checklist name="variable_10" value="problems following through on directions|unfinished tasks|difficulty with organization|is often forgetful|reluctance to engage in tasks requiring sustained attention|failing to give close attention to details/ careless mistakes|difficulty sustaining attention|problems listening when spoken to directly|misplaces things necessary for tasks and activities|easily distracted by extraneous stimuli"]

Patient ENDORSES[textarea name="variable_11" default=""] # out of 9 hyperactivity symptoms of ADHD as occurring often or very often, including [checkbox name="variable_12" value="fidgets/squirms|always on the go, driven by a motor|often leaves seat when remaining seated is expected|restlessness|trouble engaging in leisure activities|talks excessively|blurts out answers/completes other people sentences|difficulty waiting their turn|interrupts or intrudes on others"]

DEPRESSION:
Patient [select name="variable_14" value="DENIES|ENDORSES"] symptoms of DEPRESSION including
[checkbox name="variable_15" value="loss of interest in pleasurable activities|sad mood and feelings of hopelessness|sleep alteration|problems with energy|appetite disturbance|feelings of guilt or worthlessness|problems with concentration|psychomotor disturbance|passive suicidal thoughts"]

ANXIETY:
Patient [select name="variable_17" value="DENIES|ENDORSES"]symptoms of GENERALIZED ANXIETY, including[checklist name="variable_18" value="excessive worrying throughout the day associated with,|feeling nervous and on edge|constant worry|racing thoughts|trouble relaxing|feeling restless|Irritability|feelings of impending doom"]
Triggers: [textarea name="variable_19" default="sample text"]

PANIC:
Patient [select name="variable_20" value="ENDORSES|DENIES"]symptoms of PANIC ATTACKS
Triggers:[textarea name="variable_21" default="sample text"]
Frequency:[checklist name="variable_22" value="Daily|Weekly|Monthly"]

INSOMNIA:
Sleep routine:[textarea="variable_23" default="sample text"]
Hours of sleep per night:[text name="variable_24" default="sample text"]
Patient [select name="variable_25" value="ENDORSES|DENIES"] symptoms of INSOMNIA, including [checkbox name="variable_26" value="difficulty falling asleep|frequent awakenings during the night|difficulty staying asleep|waking up too early|non-restorative sleep|daytime sleepiness|difficulty concentrating due to lack of sleep"]

PAST 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"].

FAMILY PSYCHIATRIC HISTORY:
[select value="They deny knowledge of a family history of mental illness|Family history of mental health problems is positive for |Unable to cover family history of psychiatric issues due to symptomatic presentation"][textarea rows="4"]. [select value="There is no known history of suicides or self-harm in the patient's family|Family history of suicides/self-harm includes |Unable to cover family history of suicides/self-harm due to symptomatic presentation|"][textarea rows="2"]. [select value="There is no known family history of substance use issues|Family history of substance use is positive for |Unable to cover family history of substance use issues due to symptomatic presentation|"][textarea rows="4"].

SOCIAL HISTORY:
[var name="name"] identifies [checkbox value="having no one|significant other|extended family|children|friends|church members"][textarea rows="1"] as their 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 employed |currently on disability due to their mental health condition|currently on disability due to their medical condition|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="current employment|disability|social security|unemployment|family support|retirement|"][textarea rows="1"]. They have [select value="no current housing concerns|a currently unstable housing situation related to |"][textarea rows="1"]. [select name="spirituality" value="Spirituality was not addressed this visit|Spirituality is identified as |"][conditional field="spirituality" condition="(spirituality).is('Spirituality is identified as ')"][select value="Christian|Catholic|Muslim|Jewish|Spiritual but not practicing|Athiest|Agnostic|"][textarea rows="1"][/conditional]. [select value="Cultural considerations important to care include: |"][textarea rows="1"]. Sexual orientation [select name="sexuality" value="is identified as |was not addressed this visit|"][conditional field="sexuality" condition="(sexuality).is('is identified as ')"][select value="straight|gay|lesbian|bisexual|pansexual|asexual|"][textarea rows="1"][/conditional]. [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 i]

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, the 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"][conditional field="b" condition="(b).is(' with psychotherapy')"]
[comment memo="Psychiatric Add On
Psychotherapy/Interactive Complexity/Prior case management
"][checkbox value="Time spent in psychotherapy: "][checkbox value="16-37 min"][comment memo="30 min 90833"][checkbox value="38-52 min"][comment memo="45 min 90836"][checkbox value="53-67 min"][comment memo="60 min 90838"]
[checkbox value="Focus of psychotherapy: "][checkbox value="interpersonal conflict|emotional experience related to diagnosis|identification of coping mechanisms|grief counseling"][textarea memo="other" default="" rows="1"]
[checkbox value="Modality: "][checkbox value="insight oriented|supportive|behavioral modification"][textarea memo="other" default="" rows="1"][/conditional]tarea name="variable_45" default="sample text"]

*MANAGEMENT/PLAN*[conditional field="A" condition="(A).is('Followup')"][comment memo="
Risk/Morbidity/Mortality
Low (99213)= One stable chronic illness/Two or more self-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 a 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"][/conditional]
The following interventions were ordered/recommended for this appointment:
[textarea rows="3"]

[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. Client was educated on the recommendation for treatment. Client counseled to notify the clinic/provider of any side effects, adverse reaction, changes in thought, or worsening mood, SI/HI/DTO, go to ER, or call 911, or crisis hotline (988). Client verbalizes understanding and agrees with the treatment plan. "]
Diagnosis:
[checkbox value="Major depressive disorder|recurrent|single episode|mild|moderate|severe|Bipolar II|Depression|Manic|hypomania|Mixed|without psychosis |with psychosis|Generalized anxiety disorder|Insomnia|PTSD |acute|chronic|ADHD |inattentive type|hyperactive type|mixed|Adjustment Disorder|with depressed mood|with anxiety|with depressed mood and anxiety"][textarea rows="2"]

RECOMMENDED FOLLOW-UP:
The Provider and patient can communicate asynchronously via the "Consultations" tab on Done. Website. Patients can also follow up as needed with the Provider by scheduling a video follow-up appointment. This Provider would at least need the patient to schedule a video follow-up appointment every six months to monitor their progress and continue safely providing medication management closely.

*********************  Additional Notes  ******************

Patient’s preferred Pharmacy-verified and updated in the chart.
ID verification verified

Side Effect Education:
Re: Stimulants: Side effects of stimulants can include decreased appetite, insomnia, particularly if taken too late in the day, dry mouth, tics, tremors, agitation or psychosis, changes in libido, elevated heart rate, and blood pressure. Dangerous side effects could include psychotic sx, seizures, cardiovascular events, and arrhythmia. There is an increased risk of arrhythmia or cardiovascular problems in persons with a history of cardiac disease or stroke or a family history of cardiac stroke at an early age or sudden death. There is a risk of worsening or side effects of glaucoma, vision changes, or eye pain. Stimulants have a chance of dependency and addiction. People can develop tolerance necessitating increases in doses. If possible, it is helpful to take the medication only on days on which it is needed.

Informed Consent:
Psychoeducation is provided on the benefits, risks, side effects, and alternatives to the patient’s medication treatment plan. The Provider and patient discussed the danger of misuse of stimulant medications, and the patient agreed to take medication only for themselves. The patient is to contact our office with any questions, concerns, adverse side effects, or changes in mental health status. The patient is advised to call 9-1-1 or go to the nearest emergency room if the patient experiences a medical or mental health emergency, including but not limited to suicidal or homicidal ideation or plans. The patient is advised against using alcohol and illicit substances while on psychotropic medication due to the risk of negative interactions and is aware doing so will be at their own risk. It is recommended that the patient should discuss this diagnosis and treatment plan with their PCP as well, as we don't want to have overriding and conflicting plans. The patient is encouraged to follow up with PCP for routine health and lab monitoring and maintenance.

The patient verbalizes understanding, agrees to this treatment plan, and agrees to coordinate care as needed.

LaCresha Earley PMHNP BC, FNP-C, APRN
Date:
Time:

Patient name is a age-year-old, ethnicity, other gender
History of Presenting Illness:
name that names
other.presenting problem.
Mental health history.

HISTORY OF PRESENT ILLNESS:
Age of symptom onset

Current symptoms and current functional impairments across settings

Scales and Screening:
ASRS:
PHQ-9:
GAD-7:


PSYCHIATRIC REVIEW OF SYSTEMS:
ADHD:

Patient ENDORSES # out of 9 inattentive symptoms of ADHD as occurring often or very often, including

Patient ENDORSES
# out of 9 hyperactivity symptoms of ADHD as occurring often or very often, including

DEPRESSION:
Patient symptoms of DEPRESSION including


ANXIETY:
Patient symptoms of GENERALIZED ANXIETY, including
Triggers:


PANIC:
Patient symptoms of PANIC ATTACKS
Triggers:

Frequency:

INSOMNIA:
Sleep routine:

Hours of sleep per night:
Patient symptoms of INSOMNIA, including

PAST PSYCHIATRIC HISTORY:
.
.
.
.
.
.
.
.
.
.
.

FAMILY PSYCHIATRIC HISTORY:
.
.
.

SOCIAL HISTORY:
name identifies
as their social-support network. They have
children. Their level of education is
. They are
. Financially they
. Their source of income is primarily
. They have
. .
. Sexual orientation .
.

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, the patient's intelligence is judged to be
othertarea name="variable_45" default="sample text"]

*MANAGEMENT/PLAN*
The following interventions were ordered/recommended for this appointment:



Diagnosis:


RECOMMENDED FOLLOW-UP:
The Provider and patient can communicate asynchronously via the "Consultations" tab on Done. Website. Patients can also follow up as needed with the Provider by scheduling a video follow-up appointment. This Provider would at least need the patient to schedule a video follow-up appointment every six months to monitor their progress and continue safely providing medication management closely.

********************* Additional Notes ******************

Patient’s preferred Pharmacy-verified and updated in the chart.
ID verification verified

Side Effect Education:
Re: Stimulants: Side effects of stimulants can include decreased appetite, insomnia, particularly if taken too late in the day, dry mouth, tics, tremors, agitation or psychosis, changes in libido, elevated heart rate, and blood pressure. Dangerous side effects could include psychotic sx, seizures, cardiovascular events, and arrhythmia. There is an increased risk of arrhythmia or cardiovascular problems in persons with a history of cardiac disease or stroke or a family history of cardiac stroke at an early age or sudden death. There is a risk of worsening or side effects of glaucoma, vision changes, or eye pain. Stimulants have a chance of dependency and addiction. People can develop tolerance necessitating increases in doses. If possible, it is helpful to take the medication only on days on which it is needed.

Informed Consent:
Psychoeducation is provided on the benefits, risks, side effects, and alternatives to the patient’s medication treatment plan. The Provider and patient discussed the danger of misuse of stimulant medications, and the patient agreed to take medication only for themselves. The patient is to contact our office with any questions, concerns, adverse side effects, or changes in mental health status. The patient is advised to call 9-1-1 or go to the nearest emergency room if the patient experiences a medical or mental health emergency, including but not limited to suicidal or homicidal ideation or plans. The patient is advised against using alcohol and illicit substances while on psychotropic medication due to the risk of negative interactions and is aware doing so will be at their own risk. It is recommended that the patient should discuss this diagnosis and treatment plan with their PCP as well, as we don't want to have overriding and conflicting plans. The patient is encouraged to follow up with PCP for routine health and lab monitoring and maintenance.

The patient verbalizes understanding, agrees to this treatment plan, and agrees to coordinate care as needed.

LaCresha Earley PMHNP BC, FNP-C, APRN

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.58, 154 form elements, 609 boilerplate words, 10 text boxes, 50 text areas, 1 dates, 21 checkboxes, 3 check lists, 57 drop downs, 2 variables, 5 comments, 5 conditionals, 254 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: