NH FU Note for Charting App (in progress)

This note is set up for copy and paste to the ChartingApp (horrible app but required)

--INTERVAL HISTORY--

Chief Complaint:    
This is [select name="variable_1" value="a|an"] [text name="variable_2" default=""]-year-old [select name="variable_3" value="male|female| "] with a pertinent psychiatric history of [text name="variable_4" default=""] last seen by this service on [date name="variable_5" default=""] and is being seen today for [select name="variable_6" value="follow-up of    medication efficacy and tolerability |routine follow-up of medication management|urgent consult for XX"].

[comment memo="History of Psychiatric Illness per buttons in    ChartingApp"]

Patient Report:

Option A:        
The pt was evaluated[select name="variable_7" value=" in their room| in the hall| in the dining hall| in the dayroom| at the nurses' station| in the PT gym"], and privacy was secured and maintained.    Since the previous visit, the patient reports doing[select name="variable_8" value=" better| worse| well| good | slightly worse | slightly better| about the same"] and reported that medication has[select name="variable_9" value=" helped with psychiatric symptoms.| had no effect on psychiatric symptoms.| made psychiatric symptoms worse.| not changed psychiatric symptoms.| not helped psychiatric symptoms due to not taking the medication. | made psychiatric symptoms slightly worse.| had somewhat of an effect.| - the pt is not prescribed any psychotropic medications"]  The pt [select name="variable_10" value="denied any SEs to their medications| reported the following side effects to their medications:"][text name="variable_11" default=""]. 

Option B:    
Simple FU:
Patient states they have been feeling [select name="variable_12" value="good|okay|depressed|anxious|neutral/content|happy|sad|fine|well|angry|irritable|frustrated"]
Pt reports [select name="variable_13" value="0|1|2|3|4|5|6|7|8|9|10"] out of 10 depression and [select name="variable_14" value="0|1|2|3|4|5|6|7|8|9|10"] out of 10 anxiety. They [select name="variable_15" value="deny|report"] new stressors since last appointment. [checkbox name="variable_16" value="They deny new medical concerns or new medications. "]
[checkbox name="variable_17" value="Pt has no acute concerns."][checkbox name="variable_18" value="Their depression has been worsening. "][checkbox name="variable_19" value="Their anxiety has been worsening. "] Pt's sleep has been [select name="variable_20" value="good|poor|adequate|at baseline"] and their appetite has been [select name="variable_21" value="good|poor|adequate|at baseline|increasing|low"][checkbox name="variable_22" value="Pt denies suicidal thoughts, homicidal, or aggressive thoughts, or hallucinations."]

OR Free Type Pt Report:    

The Patient Reported: [textarea name="variable_23" default=""]

Staff reported [textarea name="variable_24" default=" The pt was at their baseline, and they denied witnessing any behavioral disturbances."]

[comment memo="Mental Status Exam per buttons in ChartingApp"]

[comment memo="Risks per buttons in ChartingApp"]

Commentary on Psych Functioning
[textarea name="variable_80" default=""]

Diagnosis

Primary Dx:
Plan:[textarea name="variable_81" default=""]

Secondary Dx:
Plan:[textarea name="variable_82" default=""]

Tertiaruy Dx:
Plan:[textarea name="variable_83" default=""]    

Dementia Dx:   
Plan:[textarea name="variable_84" default=""]

Additional Prob:
Plan:[textarea name="variable_85" default=""]

Additional Prob:
Plan:[textarea name="variable_86" default=""]

Medication Orders:    
Add Current Medication Order:
[textarea name="variable_87" default=""]

Add New Medication Order:
[textarea name="variable_89" default=""]

Allergies:
[comment memo="Per drop down in ChartingApp"]

Lab Orders:
Order#1    [text name="variable_90" default=""]
Order#2    [text name="variable_91" default=""]
Order#3    [text name="variable_92" default=""]

[comment memo="PsychoEducation per ChartingApp"]

Chart Review & Medical History

Med Side-Effects:  [comment memo="SE    and Allergies are Required"]  

[comment memo="Copy and paste to ChartingApp or fill in reported SE on ChartingApp"]   
-Reviewed, no reported side effects

Medication Allergies: 
[comment memo="Copy and paste to ChartingApp or fill in reported allergies on ChartingApp"]
-No new allergies reported

Recent Lab Results:

[checkbox name="CBC" value="CBC"]    [comment memo="Date"]    [date name="date_1" default=""]    [checkbox value="Unremarkable"]  [checkbox value="Hgb:"][text name="level10 default=""]    [checkbox value="Hct:"][text name="level11 default=""]       [checkbox value="Plt:"][text name="level12 default=""]    [checkbox value="ANC Level:"][text name="level13 default=""]   

[checkbox name="Metabolic" value="Metabolic    Panel"]    [comment memo="Date"]    [date name="date_2" default=""] [checkbox value="Unremarkable"] [checkbox value="Na:"][text name="level14 default=""]    [checkbox value="K:"][text name="level15 default=""]       [checkbox value="Cl:"][text name="level16 default=""]    [checkbox value="CO2:"][text name="level17 default=""]   [checkbox value="Ca:"][text name="level18 default=""]    [checkbox value="BUN:"][text name="level19 default=""]       [checkbox value="Creat:"][text name="level20 default=""]    [checkbox value="eGFR:"][text name="level21 default=""]   [checkbox value="T Prot:"][text name="level22 default=""]    [checkbox value="Alb:"][text name="level23 default=""]       [checkbox value="T Bili:"][text name="level24 default=""]    [checkbox value="Alk    Phos:"][text name="level25 default=""]   [checkbox value="AST:"][text name="level26 default=""]    [checkbox value="ALT:"][text name="level27 default=""]  

[checkbox name="Lipids" value="Lipids"]    [comment memo="Date"]    [date name="date_3" default=""]    [checkbox value="Unremarkable"]    [checkbox value="TC:"][text name="level28 default=""]    [checkbox value="TG:"][text name="level29 default=""] [checkbox value="HDL:"][text name="level30 default=""]    [checkbox value="LDL:"][text name="level31 default=""]

[checkbox name="Other" value="Other"]        [comment memo="Date"]    [date name="" default=""]     [checkbox value="A1C:"][text name="Level32" default=""]    [checkbox value="TSH:"][text name="Level33" default=""]    [checkbox value="Free T3:"][text name="Level34" default=""]   [checkbox value="Free T4:"][text name="Level35" default=""]   [checkbox value="Vit D:"][text name="Level36" default=""]    [checkbox value="Vit B12":"][text name="Level37" default=""]    [checkbox value="Ammonia:"][text name="Level38" default=""]    [checkbox value="Prolactin Level:"] [text name="level7 default=""]

[checkbox name="Druglevels" value="Drug   Levels"][comment memo="Date"]    [date name="date_4" default=""] [checkbox value="Lithium level:"][text name="level2 default=""]    [checkbox value="Depakote Level:"][text name="level3 default=""]    [checkbox value="Tegretol Level:"][text name="level4 default=""]    [checkbox value="Clozapine Level:"][text name="level5 default=""]    

[checkbox value="EKG:"]    [comment memo="Date"]    [date name="date_5" default=""] [text name="level6 default=""]

[checkbox name="Additional Labs" value="Additional Labs"][textarea name="variable_76" default=""]

Personal Psych History:[checkbox name="variable_70" value="Unknown|Denies|Anxiety|Dementia|SI|Depression|Bipolar d/o|Schizoaffective d/o|Schizophrenia|OCD|Alcohol Abuse|Substance Abuse"][text name="variable_75" default=""]

Sig medical Dxs:[checkbox name="variable_66" value="Unknown|CKD|CVA|DM|CAD|CHF|HTN|HLD|OA|RA|Lupus|MS|MI"][text name="variable_71" default=""]

Last set of VS:
BP: [text name="variable_59" default=""]|Temp: [text name="variable_60" default=""]|HR: [text name="variable_61" default=""]|RR: [text name="variable_62" default=""]|O2Sat: [text name="variable_63" default=""]

Body Mass Index (BMI)
[text name="Height"] <-- Height in inches
[text name="Weight"] <-- Weight in pounds
BMI Calculations
Class --> [calc memo="class" value="score=(Weight)*(703)/((Height)*(Height));score>59.9999?'Super-super obesity or class V obesity':score>49.9999?'Super-obesity or class IV obesity':score>39.9999?'Extreme obesity or class III obesity':score>34.9999?'Obesity class II':score>29.9999?'Obesity class I':score>24.9999?'Overweight':score>18.4999?'Normal':score>16.4999?'Underweight':'Severely underweight'"]
BMI --> [calc memo="bmi" value="score1=score.toFixed(1)"]

Social Hx:[checkbox name="variable_67" value="Unknown|Widowed|Divorced|Adopted|Children|Retired|Homelessness"][text name="variable_72" default=""]

Family Psych History:[checkbox name="variable_68" value="Denies|Unknown|Anxiety|Depression|Bipolar|Schizoaffective|Schizophrenia|Dementia|OCD|Suicide"][text name="variable_73" default=""]

Family Medical History:[checkbox name="variable_69" value="Denies|Unknown|CKD|CVA|DM|CAD|CHF|HTN|Heart Disease|HLD|OA|RA|Lupus|MS"][text name="variable_74" default=""]

Additional Summaries

Old Records:[checkbox name="variable_64" value="Unavailable|No recent progress notes, labs, testing, or other pertinent notes were completed.|Medical records, including H&P, hospital discharge/visit records, ancillary services svaluations, labs, nursing notes, and any other pertinent data in the EHR/Chart were reviewed."] 

History from 3rd Party: Coordination of care with [checkbox name="variable_65" value="nursing|social services|LCSW|DON|PT/OT/SLT|PCP|Pharmacy|family|POA/Guardian"] staff was done to facilitate the best outcomes for the patient.

Consults:
[textarea name="variable_77" default=""]


Statements and Decision to Treat:
•Based on the findings of my assessment, the above-stated goals/benefits of the recommended psychotropic drug intervention outweigh the primary risks, as noted above. I have given due consideration to this resident's available past medical history, and current medical comorbidities, including other prescribed medications, in reaching this conclusion. The resident's condition may worsen without intervention at this time. Medication intervention offers the potential to relieve the resident of severe emotional distress and improve functionality and quality of life.


[checkbox name="APA" value="APA Guidelines on Use of Antipsychotics:"]
[conditional field="APA" condition="(APA).is('APA Guidelines on Use of Antipsychotics:')"][textarea name="variable_175u3" default="Expert consensus suggests that use of an antipsychotic medication in individuals with dementia can be appropriate, particularly in individuals with dangerous agitation or psychosis, and can minimize the risk of violence, reduce patient distress, improve the patient’s quality of life, and reduce caregiver burden."][/conditional]

GDR indicated?
[radio name="variable_165464tgfs654v1" value="Yes|No"]
[conditional field="variable_165464tgfs654v1" condition="(variable_165464tgfs654v1).is('No')"][text name="variable_df51" default="DRUG NAME"]
[textarea name="variable_1gf46tyg" default="GDR Contraindicated Risk & Benefit statement: 
Target symptoms of have not been sufficiently relieved by non-pharmacological interventions. In my professional opinion, the continued use of the present medication regimen is in accordance with relevant current standards of practice. Any dose reduction at this time would likely impair resident function and cause psychiatric instability by exacerbating underlying symptoms, so the resident is NOT a candidate for Gradual Dose Reduction at the present time."][/conditional]

Prescribed AP and >65 and/or dementia?
[radio name="variable_1654643546s654v1" value="Yes|No"]
[conditional field="variable_1654643546s654v1" condition="(variable_1654643546s654v1).is('Yes')"][text name="variable_df541" default="DRUG NAME"]
[textarea name="variable_1gfret46tyg" default="GDR Clinically contraindicated for Antipsychotic Treatment related to dementing illness and associated behavioral symptoms:
A GDR is contraindicated at this time because target symptoms of *** have not been sufficiently relieved by non-pharmacological interventions or other psychoactive medications. Any type of dose reduction at this time would likely further exacerbate behavioral symptoms and present a danger to the resident or others. The BLACK BOX WARNING for this class of medications has been reviewed and based upon a risk/benefit analysis, continued use of this medication is indicated at this time. As medication is time-limited, a GDR will be reviewed and/or attempted again within 90 days."][/conditional]

This note is set up for copy and paste to the ChartingApp (horrible app but required)

--INTERVAL HISTORY--

Chief Complaint:
This is -year-old with a pertinent psychiatric history of last seen by this service on and is being seen today for .

History of Psychiatric Illness per buttons in ChartingApp

Patient Report:

Option A:
The pt was evaluated, and privacy was secured and maintained. Since the previous visit, the patient reports doing and reported that medication has The pt .

Option B:
Simple FU:
Patient states they have been feeling
Pt reports out of 10 depression and out of 10 anxiety. They new stressors since last appointment.
Pt's sleep has been and their appetite has been

OR Free Type Pt Report:

The Patient Reported:


Staff reported


Mental Status Exam per buttons in ChartingApp

Risks per buttons in ChartingApp

Commentary on Psych Functioning


Diagnosis

Primary Dx:
Plan:


Secondary Dx:
Plan:


Tertiaruy Dx:
Plan:


Dementia Dx:
Plan:


Additional Prob:
Plan:


Additional Prob:
Plan:


Medication Orders:
Add Current Medication Order:


Add New Medication Order:


Allergies:
Per drop down in ChartingApp

Lab Orders:
Order#1
Order#2
Order#3

PsychoEducation per ChartingApp

Chart Review & Medical History

Med Side-Effects: SE and Allergies are Required

Copy and paste to ChartingApp or fill in reported SE on ChartingApp
-Reviewed, no reported side effects

Medication Allergies:
Copy and paste to ChartingApp or fill in reported allergies on ChartingApp
-No new allergies reported

Recent Lab Results:

Date

Date

Date

Date

Date

Date



Personal Psych History:

Sig medical Dxs:

Last set of VS:
BP: |Temp: |HR: |RR: |O2Sat:

Body Mass Index (BMI)
<-- Height in inches
<-- Weight in pounds
BMI Calculations
Class --> classscore=(Weight)*(703)/((Height)*(Height));score>59.9999?'Super-super obesity or class V obesity':score>49.9999?'Super-obesity or class IV obesity':score>39.9999?'Extreme obesity or class III obesity':score>34.9999?'Obesity class II':score>29.9999?'Obesity class I':score>24.9999?'Overweight':score>18.4999?'Normal':score>16.4999?'Underweight':'Severely underweight'
BMI --> bmiscore1=score.toFixed(1)

Social Hx:

Family Psych History:

Family Medical History:

Additional Summaries

Old Records:

History from 3rd Party: Coordination of care with staff was done to facilitate the best outcomes for the patient.

Consults:



Statements and Decision to Treat:
•Based on the findings of my assessment, the above-stated goals/benefits of the recommended psychotropic drug intervention outweigh the primary risks, as noted above. I have given due consideration to this resident's available past medical history, and current medical comorbidities, including other prescribed medications, in reaching this conclusion. The resident's condition may worsen without intervention at this time. Medication intervention offers the potential to relieve the resident of severe emotional distress and improve functionality and quality of life.





GDR indicated?



Prescribed AP and >65 and/or dementia?



Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.53, 169 form elements, 335 boilerplate words, 55 text boxes, 16 text areas, 7 dates, 57 checkboxes, 2 radio buttons, 13 drop downs, 14 comments, 2 calculations, 3 conditionals, 211 total clicks
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