North Park version 2

Date and Time of Service: [date default=timestamp]

PATIENT NAME and room#: [textarea memo="NAME" default="" rows="1"]

CC: Guest is a [text name="variable_3" default=""] year old [checkbox name="variable_6" value="male|female"][text name="variable_70" default=" "][comment memo="other"] for [checkbox value="follow up|depression|anxiety|bipolar|mood disorder|psychosis|behavioral|PTSD"] [textarea name="variable_2" default=" " rows="1"] 

Met with guest today, and they reports mood as "[checkbox value="ok|good|fair|poor|so-so"][textarea memo="mood" default="" rows="1"]." Guest reports sleeping [checkbox value="well|is fair| is poor"]. Reports appetite is [checkbox value="good|fair|poor"]. Guest reports their anxiety as [select value="0|1|2|3|4|5|6|7|8|9|10|declined to answer|UTA, nonverbal"]/10, and reports depression as [select value="0|1|2|3|4|5|6|7|8|9|10|declined to answer|W=UTA, nonverbal"]/10. 
[textarea memo="hpi comments" default="" rows="3"] [checkbox value="Guest reports medications are working well|They report physical therapy is going well.|Denies any issues or concerns."] [textarea memo="denies issues" name="variable_11" default=" " rows="3"] [checkbox value="Guest reports they are not doing well| Reports continued symptoms."] [checkbox value="Guest complains of the following symptoms"] [textarea memo="Guest c/o" default=" " rows="3"][checkbox name="variable_8" value=" depressed mood|loss of interest/pleasure|weight loss|weight gain|insomnia| hypersomnia|psychomotor retardation|psychomotor agitation|fatigue|feelings of worthlessness/excessive or inappropriate guilt|decreased concentration/indecisiveness|excessive anxiety and worry|finds it difficult to control the worry|anxiety and worry are associated with restlessness or feeling keyed up or on edge|being easily fatigued|dificulty concentrating or mind going blank|irritability|thoughts of death/suicide|auditory hallucinations|visual hallucinations"][textarea memo="symptoms" default=" " rows="1"] [checkbox value="Guest denies any AH/VH/SI/HI/DTS/DTO."][comment memo="****"]
[checkbox value="Guest denies |auditory or visual hallucinations| hallucination|visual hallucinations|racing thoughts|excessive worry|suicidal ideation|homicidal ideation|thoughts of self-harm or self-injury|thoughts of harm to others"] [textarea memo="other" default="" rows="1"] [checkbox value="Guest was provided support and therapeutic listening to reduce anxiety and depression."] [checkbox value="No reports of any mood fluctuations by guest or staff."]

VITALS: [checkbox value="Reviewed|WNL|Abnormal"]

ESTABLISHED MEDICAL DIAGNOSIS: 

PSYCHIATRIC DIAGNOSES: [checkbox name="variable_30" value="F41.1 Generalized Anxiety Disorder|F33.1 Major depressive disorder, recurrent, moderate|F32.1 Major depressive disorder, single episode, moderate|F43.21 Adjustment disorder with depressed mood|F31.9 Bipolar Disorder, unspecified|F25.9 Schizoaffective Disorder|F25.0 Schizoaffective bipolar type|F29 Unspecified psychosis|F39 Unspecified Mood disorder|F43. 10 Post-Traumatic Stress Disorder|F42 Obsessive-compulsive disorder|G47.0 Insomnia"][textarea memo="other ICD-10" default="" rows="1"]

PSYCHIATRIC MEDICATIONS: [textarea memo="Current Rx" default="" rows="2"]

MENTAL STATUS: GENERAL: [select value="Alert|Sleepy"]
ORIENTATION: [select value="Alert and oriented with appropriate responses|Person|Place|Date|Situation|with appropriate responses|Disoriented"]
EYE CONTACT: [select value="appropriate|good|poor"]
SPEECH: [select value="normal rate, tone, volume|slow rate|rapid speech|low volume|loud volume|non verbal"] [select value="|slow rate|rapid speech|low volume|loud volume|non verbal"]
MEMORY/CONCENTRATION/COGNITION: [select value="Intact|Forgetful|Disoriented|Impaired"]
THOUGHT PROCESS AND CONTENT: [select value="Intact, Linear W/O disorder|logical, Goal-Directed|illogical at times|Paranoia| Delusions|disorganized|tangential"] [select value="|Intact, Linear W/O disorder|logical, Goal-Directed|illogical at times|Paranoia|Delusions|disorganized|tangential"]
INSIGHT/JUDGMENT: [select value="Intact|Good|Fail|Poor"] 
AFFECT and MOOD: [select value="Euthymic|Depressed|Neutral|Manic|Angry|Anxious"] [select value="|Euthymic|Smiling|Neutral|Appropriate to mood|Not appropriate|Blunted|Flat|Labile|irritable|tearful"][textarea name="other" default=" " rows="1"]

[checkbox value="Patient goals and Strengths: |To walk better|To go home|stable mood|report improvement of symptoms"] [textarea memo="goals" default="" rows="1"]
[checkbox value="LABS: | Reviewed|none available"]
[checkbox value="Guest denies a history of substance or alcohol abuse."] [textarea memo="ETOH/drug use: qty,freq,last drink" default="" rows="1"]

ASSESSMENT: [checkbox value="Guest is doing well|tolerating medication|Mood is stable|Guest reports continued symptoms|Mood is unstable|Medication therapy needs adjustment."]

Assessment of overall level of risk: [select value="low risk of acute dto or dts|high risk of acute dto or dts"] [checkbox value="Minimal acute risk factors|Several protective factors|Patient reports family and community supports."] [checkbox value="No labs ordered at this visit. No imaging was requested at this visit|Identified goals and provided support for patient to utilize strengths to accomplish goals."]

Dx: [var name="variable_30"] [textarea memo="ICD 10" default="" rows="1"]
PLAN: [select value=" Continue current medication regimen. |Medication change|Continue to follow and monitor."] [textarea name="variable_12" default="" rows="2"][comment memo="med change"] [checkbox value="Discussed med changes."] [select value="|Guest denies concerns about discharge plan.|Guest reports anxiety about discharge plans.| Guest reports concerns about discharge plans. Will follow up with CM.|"] [select value="Plan is to continue psychiatric medication due to chronicity of symptoms and established diagnosis. Medication continuation is warranted to continue psychiatric stability.| Plan is to taper psychiatric medications once appropriate and symptoms reduced. Recommend therapy and nonpharmacological treatment when appropriate and symptoms have reduced.|"] [select value="Follow up to assess for negative behaviors, medication efficacy, and supportive therapy.|"] [select value="Therapy recommendation: Recommended therapy when willing and able.|"] [select value=" Staff advised to contact crisis team if dto or dts statements or behaviors and to contact this writer or office.|"] [select value="Provide assessment, therapeutic listening, and medication management to reduce psychiatric symptoms. |"] [select value="Summary of initial treatment target/meds.|"] [select value="Offer medication management to treat symptoms. Encourage therapy to address symptoms. Safe and therapeutic milieu.|"]