Medication Management-Follow-UP
[text name="variable_1" default="sample text"] [text name="variable_1" default="sample text"] Given the current spread of COVID 19 and this agency's limited access to comprehensive HIPAA-compliant technology, this session was completed [checkbox name="variable_1" value="over the phone|over Zoom Telepsych platform"] 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* Client is a [text name="variable_1" default=" "] year old[checklist name="variable_1" value="male|female"] with [text name="variable_1" default=" "] presents today for a follow-up evaluation with a chief complaint of "[textarea memo="quotes" default="" rows="1"]" Last seen [text name="variable_1" default=" "][comment memo="LAST VISIT"][checkbox value="the following changes were made to client's treatment: |no changes were made to client's treatment plan"][textarea memo="other" default="" rows="1"]. Client [checkbox value=" presents with new symptoms of| presents with worsening symptoms of|denies new or worsening symptoms|reports improved symptoms of|reports"][textarea memo="other" default="" rows="1"]. [checkbox memo="depression" name="dep" value=""][checkbox memo="anxiety" name="anx" value=""][checkbox memo="adhd" name="adhd" value=""][checkbox memo="sleep" name="sleep" value=""][checkbox memo="mood disorder" name="mood" value=""][conditional field="anxiety" condition="(anxiety).is('')"][/conditional][conditional field="dep" condition="(dep).is('')"]Depression is reported to be [select value="stable|better|somewhat better|somewhat worse|much worse| "][text]. [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea]. Depression is reported to be present [select value="occasionally|almost never|about 50% of the time|most of the time on most days|almost always|"][text]. Depression is rated at [select value="1|2|3|4|5|6|7|8|9|10"]/10 with 10 being the worst. [textarea][/conditional][conditional field="anx" condition="(anx).is('')"] Anxiety is reported to be [select value="stable|better|somewhat better|somewhat worse|much worse| "][text]. [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|lack of response to medications|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea]. Anxiety is reported to be present [select value="occasionally|mostly around situational stressors|almost never|about 50% of the time|most of the time on most days|almost always|"][text]. Anxiety is rated at [select value="1|2|3|4|5|6|7|8|9|10"]/10 with 10 being the worst. [textarea][/conditional][conditional field="adhd" condition="(adhd).is('')"] ADHD is reported to be [select value="stable|better|somewhat better|somewhat worse|much worse| "][text]. [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|lack of response to medications|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea]. Inattention is reported to be present [select value="occasionally|mostly around situational stressors|almost never|about 50% of the time|most of the time on most days|almost always|"][text]. [textarea][/conditional][conditional field="sleep" condition="(sleep).is('')"] Sleep is reported to be [select value="stable|better|somewhat better|somewhat worse|much worse| "][text]. [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|lack of response to medications|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea]. Insomnia is reported to be present [select value="occasionally|mostly around situational stressors|almost never|about 50% of the time|most of the time on most days|almost always|"][text]. [textarea][/conditional][conditional field="mood" condition="(mood).is('')"] Mood disorder is reported to be [select value="stable|better|somewhat better|somewhat worse|much worse| "][text]. [select value="Current stability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "][checkbox value="continuation of current medications|recent medication changes|lack of response to medications|situational stressors|lifestyle improvements|engaging in individual therapy"][textarea]. They report [checkbox value="depression|anxiety|irritability|mania|hypomania|impulsivity|emotional lability|"][text] to be present [select value="occasionally|mostly around situational stressors|almost never|about 50% of the time|most of the time on most days|almost always|"][text]. [textarea][/conditional] [select value="They deny wanting medication changes at this time|They are open to considering further medication adjustments for the treatment of |They are requesting medication adjustments for treatment of |"][text]. [textarea] Client reports they are sleeping on average [select name="sleep" value="0|1|2|3|4|5|6|7|8|9|10"] hours per night. Patient [comment memo="side effects"][checkbox value="denies medication side effects|endorses medication side effects"][textarea memo="other" default="" rows="1"]. [checkbox name="variable_1" value="No evidence of psychotic phenomenon;|Denies SI / HI / intent / plan|No acute medical concerns that would be contributing to current symptoms."] *Review of Systems* [comment memo="Include for 99213 thru 99215"] Sub use: Last use of Cannabis: [text name="variable_1" default=" "]; Methamphetamines: [text name="variable_1" default=" "]; Cocaine: [text name="variable_1" default=" "]; Heroin: [text name="variable_1" default=" "]; EcStasy: [text name="variable_1" default=" "]; Tobacco: [text name="variable_1" default=" "]; ETOH: [text name="variable_1" default=" "]; *Past/Family/Social History* [comment memo="Include for 99214 + 99215"] [textarea rows="3"] Mental Status Exam [comment memo=" 99212 requires 1 99213 requires 6 99214 requires 9 99215 requires ALL"] 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 value="Steady gait while walking, normal strength bilaterally|"][checkbox value="unsteady gait while walking|clumsy|unable to ambulate|in bed|in wheelchair|rigid|normal strength bilaterally|weakness noted in "][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|labile|anxious|flattened|restricted|irritable|happy|full range"][textarea memo="other" default="" rows="1"] Speech: [select value="Normal rate and rhythm, not pressured|pressured|paucity|soft"][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 |"][select value="|, able to name objects|[select value="|, able to repeat phrases"][select value="|unable to assess due to cognitive impairment"][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, 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"] 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 progress in achieving treatment goals 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 following notes:"][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"] ASSESSMENT Patient is currently displaying [select value="symptoms of|well managed|moderately managed|poorly managed"] [checkbox value="depression|anxiety|sleep disturbance|psychosis|substance use disorder|cognitive impairment|impulsivity|mood lability|alcohol dependence|opioid 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 substance use disorder|their trauma history|their depressive disorder|their anxiety disorder|their bipolar disorder|interpersonal/family conflict|the stressors of a rigorous substance use program|maladaptive behaviors|poor 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 psychotropic intervention|current apprehension to engage in structured substance use treatment|current emotional distress due to unresolved trauma|limited social supports|dysfunctional interpersonal relationships|poor insight"][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|high intelligence"][textarea memo="strengths" rows="1"]. [textarea rows="5"] PLAN: [textarea rows="5"]to treat [checkbox value="mood lability|depression|anxiety|cravings|insomnia|trauma symptoms|hallucinations|paranoia|compulsions"][textarea memo="other" default="" rows="1"] [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. "] Labs ordered: [checkbox value="no|yes, CBC, CMP, thyroid panel, Vit. B, Vit. D, lipid panel"][textarea memo="other" default="" rows="1"] Follow up with PCP for acute medical concerns Follow-up in[text name="variable_1" default=" "] [text name="variable_1" default="sample text"]
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Sandbox Metrics: Structured Data Index 0.53, 171 form elements, 177 boilerplate words, 26 text boxes, 47 text areas, 38 checkboxes, 1 check lists, 42 drop downs, 11 comments, 6 conditionals, 264 total clicks
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