LUFU

PSYCHIATRIC PROGRESS NOTE

Date of Service:  [date name="variable_1" default=""]
Start time:  [text name="variable_2" default=""]
Stop time:  [text name="variable_3" default=""]
Location:  This visit was conducted [select name="variable_4" value="via OTN|in office|by phone due to inability to connect to OTN"]

Diagnoses:  [textarea name="variable_5" default=""]

Current Psychiatric medications:  [textarea name="variable_6" default=" "]

Side Effects or Medication Concerns:  [textarea name="variable_7" default="none"]

Subjective:  [textarea name="variable_8" default=""]

Objective: 
Appearance is [text name="variable_9" default="unremarkable"]. Engagement is [text name="variable_10" default=""]. Speech is [text name="variable_11" default="normal"]. Observed motor exam is [text name="variable_12" default="normal"]. Thought process is [text name="variable_13" default="goal directed"]. There is [text name="variable_14" default="no"] suicidal ideation. There is [text name="variable_15" default="no"] homicidal ideation. Mood is [text name="variable_16" default=""]. Affect is [text name="variable_17" default=""]. Memory is [text name="variable_18" default="conversationally intact"]. Attention is [text name="variable_19" default="normal"]. Insight is [text name="variable_20" default=""]. Judgment is [text name="variable_21" default=""]

Labs/tests/documents reviewed:  [textarea name="variable_22" default="none"]

Assessment:  [textarea name="variable_23" default=""]

PLAN:
1. Medications:  [textarea name="variable_24" default=""]
2. Psychotherapy:  [textarea name="variable_25" default=""]
3. Labs/tests/referrals ordered:  [textarea name="variable_26" default="none"]
4. Follow up:  [date name="variable_27" default=""]. The patient was instructed on when/how to contact the clinic and when/how to access crisis resources. 

Diagnosis, medication choices and their efficacy and potential side effects, and the risks and benefits of all treatment options and of no treatment were discussed and the patient agrees to the treatment plan.