Add on

Patient was seen for MD Add through [select name="mode" value="zoom|phone|inperson encounter"]
During the encounter patient was informed that MD ADD on is a basic requirement for the completion of intake documentation and if needed there will be a follow up session for psychiatric evaluation where either writer or a team member will do a complete psychiatric evaluation. 

[textarea name="evaluation" default="During the session patient was calm and cooperative, forthcoming with the information. Patient denied any acute concerns related to depression, anxiety or psychosis. Patient has been compliant with their medications and denied any side effects from the medications."]

Current medications include: 
[textarea name="medications" default="Denied"]
Allergies: 
[textarea name="allergies" default="NKDA"]
Medical Hx: 
[text name="Medical" default="Denied"]
PCP: [text name="PCP" default="Denied"]
Last Physical Examination: [text name="Physical" default="Recent"]

Istop:
Comments:[textarea name="variable_5" default=""]

Substance Use:
Primary substance :[textarea name="variable_6" default=""] 
Last Use: [textarea name="variable_7" default=""]  
Other substance use:  
Patient [select name="variable_3" value="endorsed|denied"] using any other    substances[textarea name="variable_8" default=""]

At this time patient [select name="withdrawal" value="Denied having any|endorsed    having|"]withdrawal symptoms 
[textarea name="details" default=""]


MSE:    
Appearence:[select name="variable_2" value="limited due to nature of the encounter|well   kempt, good personal hygiene|poor personal    hygiene"]
Eye contact: good
behaviour : calm and cooperative    
Mood:[textarea name="variable_3" default=""]
Affect: [textarea name="variable_4" default=""]
TP: logical and linear    
TC: denied SHIIP
Perceptions:denied AVH    
insight: good    
judgement : good    


Plan:
Based on patient’s current presentation patient appears appropriate for the clinic. They denied having any withdrawal symptoms, denied having any acute safety concerns, outpatient level of care will be appropriate. 
Based on patient’s hx [select name="pe" value="complete|no"] psychiatric evaluation will be scheduled