MSE v1
Patient is [select name="variable_1" value="WDWN|not WDWN"] with [select name="variable_1" value="good|poor"] hygiene, dressed in [select name="variable_1" value="appropriate|inappropriate|"] attire and in [select name="variable_1" value="no acute|acute"] distress. Patient is [select name="variable_1" value="polite|hostile|suspicious"] and [select name="variable_1" value="generally cooperative|defensive|easily distracted"] and has [select name="variable_1" value="good|poor"] eye contact. [select name="variable_1" value="No response to internal stimuli|Response to internal stimuli"] is noted. [select name="variable_1" value="No psychomotor retardation|psychomotor retardation"] is noted. [select name="variable_1" value="No agitation|agitation"] is noted. [select name="variable_1" value="No abnormal|Abnormal"] movements are noted. Speech normal in rate, tone and volume. Speech has good spontaneity. Mood is ??. Affect is congruent with mood. Patient is logical and linear in their thought process and appropriately able to engage and answer questions during interview. The patient denies suicidal or homicidal ideation. Patient denies auditory or visual hallucinations. Thought content was devoid of auditory, visual or tactile hallucinations and no acute psychosis or mania is observed. Patient denies feelings of paranoia, suspicion or derealization. Patient is alert and oriented to person, place, date and time (A&Ox3). Attention, concentration and memory are grossly intact. Judgment and insight are both appropriate as evidenced by patient's awareness of their mental health and illness, presenting here on voluntary basis, motivation in achieving treatment objectives of reduction of symptoms and continuing in follow-up care recommendations. Patient exhibits capacity to understand the consequences of their own behaviors and ability to make decisions to ensure the safety of self and others. Patient is also contracting for safety.
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 1, 11 form elements, 190 boilerplate words, 11 drop downs, 11 total clicks
More SOAPnotes by this Author:
Send Feedback for this SOAPnote