Psychiatry
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[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|partnered"] [checkbox value="cis-gender female|cis-gender male|transgender female|transgender male|gender non-binary individual"] who [select value="lives with their significant other|lives with their family|lives alone|is homeless|lives with their parents|lives with their children|lives with a roommate|lives in a grouphome|"][text size="20"] in [text memo="residing location" size="20"]. [select value="They are their own guardian|They have a DHS guardian |Their guardian is |"][text memo="guardian" size="20"]. [textarea memo="Additional presentation information" rows="5"]


[var name="name"] presented to the emergency department [select value="alone|with family |with significant other |with DHHS worker |with case manager |by police|"][text memo="names" size="20"][select value=" for 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"].

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 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"].

MEDICAL HISTORY
[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"].

[checklist name="Substance Use" value="Tobacco use, current|Previous tobacco use|Never smoker|Alcohol use, occasional|Alcohol use, daily/heavy|No alcohol use|Cannabis|Opiates|Amphetamines|Cocaine|"][text name="Other"]

MENTAL STATUS EXAM
General: [select name="variable_2" value="alert and oriented in all spheres|obtunded|disoriented"].
Appearance: [select name="variable_3" value="well kempt|poorly kempt|appropriately dressed|inappropriately dressed|appropriately groomed|inappropriately groomed"].
Behavior - general: [select name="variable_4" value="in no acute distress|in acute psychological distress"].
Behavior - stability: [select name="variable_5" value="calm|agitated|labile"].
Behavior - interactivity: [select name="variable_6" value="warm with comments and behavior|interactive|withdrawn|indifferent"].
Behavior - eye contact: [select name="variable_7" value="eye contact good|eye contact fair|eye contact avoidant"].
Mood/Affect - stated: [select name="variable_8" value="normal|upbeat|euthymic|depressed"].
Mood/Affect - emotional range: [select name="variable_9" value="normal|broad|restricted"].
Mood/Affect - intensity: [select name="variable_10" value="normal|expansive|blunted|flat"].
Mood/Affect - congruence: [select name="variable_11" value="mood is congruent with affect|mood and affect are not congruent"].
Thought form and content: [select name="variable_12" value="normal|future oriented|logical, linear and goal-oriented|past oriented and somber|goal directed|scattered|hopeful|remorseful|enthusiastic|resigned"]
Attention: [select name="variable_13" value="no difficulty with attention or concentration|had some attentional and concentration problems during the exam"].
Perception - insight: [select name="variable_14" value="normal insight|poor insight"]
Perception - general: [select name="variable_15" value=normal|normal - denied any preoccupations, obsessions, delusions, hallucinations or perceptual disturbances"]
Cognition/Memory: [select name="variable_16" value="normal|grossly intact|below average|above average"].
Cognition/Memory - abstraction: [select name="variable_17" value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"]
Judgment: [select name="variable_18" value="normal|poor|good"].
Suicide/Assault: [select name="variable_19" value="no current or past ideation or intent|denies an active sense of wanting to harm self or others|present but without intent or plan|resolved"].
Patient is currently assessed to be at [select name="variable_20" value="low|moderate|high"] risk for self harm or harm to others as evidenced by ideation and behavior on today's exam.

PHYSICAL EXAM
[text name="name" memo="+PE findings" size="20"]

-Skin --
[checkbox value="clear, no lesions, no rash|track/needle marks"]
-HEENT --
[checklist value="EOMI|PERRLA|moist mucous membranes|neck supple|no thyromegaly|thyroid nontender without nodules|no LAD"]
-Heart --
[checklist value="RRR, normal S1/S2|no m/r/g|no peripheral edema|pulses 2+ all"]
-Lungs
[checkbox value="CTAB|BSE b/l"]
-Abdomen
[checkbox value="BS normal x4|soft, nontender, nondistended, no masses"]
-Neuro/MS
[checklist value="cranial nerves II-XII intact|moves all extremities equally, no gross motor deficits|normal sensation all 4 extremities|DTRs 2/4 x4|gait normal/stance stable|no cogwheeling on passive ROM"]
Patient name is a age-year-old, ethnicity, who in residing location. guardian.Additional presentation information


name presented to the emergency department namespresenting problem. Mental health history.

PSYCHIATRIC HISTORY:
. . . . .

MEDICAL HISTORY
. .



MENTAL STATUS EXAM
General: .
Appearance: .
Behavior - general: .
Behavior - stability: .
Behavior - interactivity: .
Behavior - eye contact: .
Mood/Affect - stated: .
Mood/Affect - emotional range: .
Mood/Affect - intensity: .
Mood/Affect - congruence: .
Thought form and content:
Attention: .
Perception - insight:
Perception - general:
Cognition/Memory: .
Cognition/Memory - abstraction:
Judgment: .
Suicide/Assault: .
Patient is currently assessed to be at risk for self harm or harm to others as evidenced by ideation and behavior on today's exam.

PHYSICAL EXAM
+PE findings

-Skin --

-HEENT --

-Heart --

-Lungs

-Abdomen

-Neuro/MS

Result - Copy and paste this output:

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