Nursing Home Psych Follow-Up with add-on PT, MSE, RBA, RBA statement, and consent

Add-on therapy? [radio name="variable_155tf" value="Yes|No"][conditional field="variable_155tf" condition="(variable_155tf).is('Yes')"]
Goal: [checkbox name="variable_45frsdafgjhf1" value="-Reduce worry|-Improve mood|-Improve frustration tolerance|-Improve sleep|-Healthy coping|-Improve distress tolerance"]
Interventions: 
[checkbox name="variable_1fghdsf444fgh44" value="brief supportive psychotherapy|feeling validation|active listening|emotional support|reassurance offered|requested clarification|cognitive distortion exploration|reflected on current themes|problem-solving|mindfulness and grounding techniques|sleep hygiene|box breathing|incorporated DBT|distress tolerance exercises|boundary setting|Five Things|life review|frustration tolerance exercises|psychoeducation|homework assigned|administered MoCA"]
Response: [textarea name="variable_1455gf" default="The pt reported that .  These were explored with the patient.  The patient was receptive to education and intervention.  The patient reported feeling better after the session."]
Plan:
[checkbox name="variable_3456fgjh1" value="-Psychotherapy with psychological services as needed|-Brief psychotherapy with med management sessions as needed|-Complete assigned homework|-Continue working on mindfulness skills|-Continue developing mature coping mechanisms"]
[/conditional]

Is the pt able to participate in the interview?
[radio name="quest" value="Yes|No"]

•PRESENT ILLNESS
--INTERVAL HISTORY--

This [select name="variable_r6ng" value="nursing home|HFA"] psychiatric visit was conducted[select name="variable_1" value=" in person.| via telepsychiatry."]  The pt was evaluated[select name="variable_1a" value=" in their room| in the dialysis suite| in the hall| in the dining hall| in the dayroom| at the nurses' station| in the PT gym"], and privacy was secured and maintained.

[conditional field="quest" condition="(quest).is('Yes')"][text name="variable_0isdfh" default="**FIRST NAME**"] [text name="varsdf3" default="**LAST NAME**"] is [select name="variable_1488fsd" value="a|an"] [text name="variable_1sdkkjsd" default=""]-year-old [select name="variable_sdf564g1" value="male|female| "] with a pertinent psychiatric history of [text name="variable_tds41sdf" default=""] last seen by this service on [date name="variable_1436tdgf" default=""] and was seen today for [select name="variable_14235gdsfgbdf" value="psychiatric follow-up and continued medication management|routine follow-up|urgent follow-up for |discharge"][text name="variable_1sd43tm" default=""].  The pt is currently prescribed [text name="variable_1sdf34t35ygbdhf" default=""].  
[comment memo="YOU ONLY HAVE TO CHANGE THE FIRST HE/SHE HIS/HER"]
[text name="variable_0isdfh" default="WILL MATCH ABOVE"] has [select name="vari_stable" value="been stable in the interval between sessions.|had an interval worsening ***|had an interval improvement ***"] [select name="var65rf" value="He|She"] reported [select name="va346" value="his|her"] Sleep as[select name="variable_2161" value=" at baseline and good overall,| adequate,| INADEQUATE,| AWFUL/BAD,| better,| WORSE,| UTA,"] [select name="va346" value="his|her"] Appetite as[select name="variable_45671" value=" at baseline and good overall,| adequate,| INADEQUATE,| AWFUL/BAD,| better,| WORSE,| UTA,"] [select name="va346" value="his|her"] Anxiety as [select name="variable_34731" value="nonexistent,|MILD,|MODERATE,|SEVERE,|better,|WORSE,|UTA,"] and [select name="va346" value="his|her"] Depression as [select name="variable_343001" value="nonexistent.|MILD.|MODERATE.|SEVERE.|better.|WORSE.|UTA."] [select name="var65rf" value="He|She"] [select name="variable_431" value="denied any suicidal ideation and contracted for safety.| reported PASSIVE suicidal ideation/DEATH WISHES and contracts for safety and will not act on it.|reported suicidal ideation and can not contract for safety.|SI CANNOT BE ASSESSED"] [select name="var65rf" value="He|She"] [select name="variable_69691" value="denied self-harm.|reported self-harm recently and does not contract for safety.|reported self-harm recently.|SELF-HARM CANNOT BE ASSESSED"] [select name="var65rf" value="He|She"] [select name="variable_4561" value="denied homicidal ideation.|reported homicidal ideation.|HOMICIDAL IDEATION CANNOT BE ASSESSED."] [select name="var65rf" value="He|She"] [select name="variable_7891" value="denied hallucinations.|REPORTED HALLUCINATIONS in the form of |denied hallucinations but displayed symptoms consistent with reacting to internal stimuli.|nursing staff report that the pt displays symptoms consistent with reacting to internal stimuli.|HALLUCINATIONS CANNOT BE ASSESSED"] [select name="var65rf" value="He|She"] [select name="variable_7791" value="denied delusions.|HAD DELUSIONS in the form of ***"] [select name="var65rf" value="He|She"] [select name="variable_2561" value="denied any mood swings.|reported having mood swings.|MOOD SWINGS CANNOT BE ASSESSED."]  Facility staff reported [textarea name="variable_345341" default="that the pt has been at their baseline, and they denied witnessing any behavioral disturbances in the interval."][/conditional]

[conditional field="quest" condition="(quest).is('No')"]The pt remains unable to participate in the interview.  Facility staff reported [textarea name="variable_345341" default="that the pt has been at their baseline, and they denied witnessing any behavioral disturbances in the interval."][/conditional]

Interview complicated? [radio name="variable_15565tf" value="Yes|No"][conditional field="variable_15565tf" condition="(variable_15565tf).is('Yes')"]
Complications resulting in the patient being a poor historian: [checkbox name="variable_45frgjhf1" value="advanced dementia|disorientation|delirium|selective mutism|language barrier|aphasia|memory impairment|significant mental illness|significant medical illness|hearing impairment|communication impairment"]
Independent history received?: 
[checkbox name="variable_1fgh333fgh44" value="Yes|No"]
From whom?: [checkbox name="variable_654yut8sdaf234fghjk" value="unit nurse|nursing management|activities director|CNA|social services|family|facility staff| facility management"]
[text name="variable_122550km" default=""]
[/conditional]

[comment memo="If Psychiatric Exam is completely normal, make no changes below"]

•PHYSICAL EXAM
--PHYSICAL EXAM FINDINGS--

Last set of VS:
BP: [text name="variable_1745fghj" default="/"]| Temp: [text name="variable_1rfgtyrtyghf5" default="ºF"]| HR: [text name="variable_345ertyfghj" default=""]| RR: [text name="variable_654dsgf" default=""]| O2Sat: [text name="variable_dsf233ew246e3r4tf" default="%"]
[conditional field="quest" condition="(quest).is('Yes')"] 

MSE
Orientation: alert and oriented [select name="variable_1dded" value="x 4|x 3|x 2|x 1|x 0| UTA"] [text name="variable_1ori" default=""]
Appearance: [select value=" normal| OBTUNDED| DISORIENTED| HYPERALERT"],[select name="variable_1o9oooi" value=" appropriately dressed, groomed, and/or kempt| INAPPROPRIATELY DRESSED, GROOMED, AND/OR KEMPT"],[select value=" normal posture| SLUMPED| RIGID| TENSE|-"].[textarea cols="20" rows="1"]
Behavior: [select value="calm|RESTLESS|AGITATED|RETARDED|PECULIAR|IMPULSIVE"],[select value=" interactive| WITHDRAWN| NONINTERACTIVE"],[select value=" eye contact good| eye contact AVOIDANT| eye contact INTENSE| eye contact FLEETING| eye contact FAIR"]. [textarea cols="20" rows="1"]
Attitude: [checkbox value="cooperative|NONCOOPERATIVE|HOSTILE|OVERLY FRIENDLY|SECRETIVE|EVASIVE|SUSPICIOUS|APATHETIC|EASILY DISTRACTED|FOCUSED|DEFENSIVE|DEMANDING|SEDUCTIVE"]. [textarea cols="20" rows="1"]
Speech: [select name="spontn" value="spontaneous|NON-SPONTANEOUS|MUTISM"],[select name="rt" value=" normal reaction time| INCREASED REACTION TIME| DECREASED REACTION TIME| VARIABLE| "],[select name="rate" value=" normal rate| SLOW| POVERTY| PAUCITY| RAPID| OVERTALKATIVE| PRESSURED| "],[select name="vol" value=" normal volume| LOUD| SOFT| WHISPHER| MONOTONE| "],[select name="rhythm" value=" clear rhythm| SLURRED| HESITANT| APHASIC| DYSPHASIC| DYSARTHRIC| "].[textarea cols="20" rows="1"]
Mood was reported as: "[textarea cols="20" rows="1"]," inferred as[checkbox value=" euthymic| NOT REPORTED| ANXIOUS| DEPRESSED| DYSPHORIC| IRRITABLE| ELEVATED| EXPANSIVE| ELATED| EUPHORIC| ANGRY| HOSTILE| INDIFFERENT| DETACHED| ANIMATED| "]
Affect: [checkbox value="euthymic|ANXIOUS|DEPRESSED|DYSPHORIC|IRRITABLE|ELEVATED|EXPANSIVE|ELATED|EUPHORIC|ANGRY|HOSTILE|INDIFFERENT|DETACHED|ANIMATED"], [select value="range normal|BROAD|RESTRICTED|-"], [select value="intensity normal|intensity EXPANSIVE|intensity CONSTRICTED|intensity BLUNTED| intensity FLATTENED| "], [select value="stability normal|stability LABILE|EMOTIONAL INCONTINENCE"], [select value="appropriate and congruent|INAPPROPRIATE|INCONGRUOUS|FATUOUS"] 
Thought form: [select value="coherent|INCOHERENT|CANNOT BE ASSESSED"], [checkbox name="variable_145dhfg" value="logical, and goal-directed|DISORGANIZED|CIRCUMSTANTIAL|TANGENTIAL|LOOSENING|FLIGHT OF IDEAS|NEOLOGISM|BLOCKING|VERBAL PERSEVERATION|CONFABULATION|CIRCUMFERENTIAL"][textarea cols="20" rows="1"]
Thought content: [select value="no delusions on current evaluation|DELUSIONS PRESENT|DELUSIONS CANNOT BE ASSESSED"],[select value=" no active suicidal ideations at present| SUICIDAL IDEATIONS PRESENT| DEATH WISHES PRESENT| SI CANNOT BE ASSESSED"]. [textarea cols="20" rows="1"]
Perception: [select value="no hallucinations on current evaluation|HALLUCINATIONS|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="1"]
Insight: [select value="present|PARTIAL|POOR|MOSTLY BLAMES OTHERS|DIFFICULTY IN ACKNOWLEDGING PRESENCE OF PSYCHIATRIC SYMPTOMS|CANNOT BE ASSESSED"]. [textarea cols="20" rows="1"]
Judgment: [select value="intact|FAIR|IMPAIRED|CANNOT BE ASSESSED"]. [textarea cols="20" rows="1"]
Memory/Cognition: [select value="intact - normal attention, concentration, intact ability to recall recent and remote information, normal abstraction|ABNORMALITIES PRESENT|PENDING|CANNOT BE ASSESSED"].[/conditional]
Psychiatric Exam:
[conditional field="quest" condition="(quest).is('No')"]
The subjective portion of the psychiatric exam could not be evaluated given the pt's inability to or unwillingness to participate.[/conditional]

--COLLABORATION--

Medical records, including H&P, hospital discharge/visit paperwork, PHQ-9, BIMS, ancillary services evaluations, most recent labs, and any other pertinent data in the EHR

The above-referenced documents were reviewed and noted.  Coordination of care with nursing and social services staff was done to facilitate the best outcomes for the patient.

Any changes in the pt's medical condition, most recent vital signs, and relevant labs were noted.

Nursing staff, social services, activities director, registered dietician, nursing management, and other members of the IDT.

The pt’s history and psychiatric needs were discussed in detail to develop a plan of care to facilitate the best outcomes for the patient.  Specific conversations are noted in the HPI or elsewhere in this note.

--ASSESSMENT--
[text name="variable_0isdfh" default="NAME WILL APPEAR AS ABOVE"] is [select name="variable_1488fsd" value="a|an"] [text name="variable_1sdkkjsd" default=""]-year-old [select name="variable_sdf564g1" value="male|female| "] who was seen today for follow-up.

DSM-5-TR Diagnoses:
•Condition #1 - [text name="variable_1avsdva" default=""]: [comment memo="Conditions entered here will appear in the PLAN section below"]
-[select name="variable_2jgwte4" value="Ongoing|NEW|Stable|Acute Exacerbation"]
-
•Condition #2 - [text name="variable_sdf4351" default=""]:
-[select name="variable_324te4" value="Ongoing|NEW|Stable|Acute Exacerbation"]
-
•Condition #3 - [text name="variable_sdf1544" default=""]:
-[select name="variable_465te4" value="Ongoing|NEW|Stable|Acute Exacerbation"]
-
•Condition #4 - [text name="variable_2wgfe" default=""]:
-[select name="variable_34gfd" value="Ongoing|NEW|Stable|Acute Exacerbation"]
-

RISK-BENEFIT ANALYSIS
[checkbox name="ssri" value="SSRI/SNRI/SPARI/TRINTELLIX"]
[conditional field="ssri" condition="(ssri).is('SSRI/SNRI/SPARI/TRINTELLIX')"][textarea name="variable_1" default="headaches, fatigue, ejaculatory delay, impotence, anorgasmia, GI distress, abnormal bleeding, SIADH and sodium levels should be monitored regularly, (Citalopram: Dose-dependent QT interval prolongation -maximum dosage 20 mg> 65 y.o.), BLACK BOX WARNING: Increased risk of suicidal thoughts and behavior in pediatric and young adult patients taking antidepressants;"][/conditional]
[checkbox name="moods" value="Mood Stabilizers"]
[conditional field="moods" condition="(moods).is('Mood Stabilizers')"][textarea name="variable_2" default="hematological and liver abnormalities, GI upset, appetite changes, thrombocytopenia, BLACK BOX WARNING: VALPROIC ACID-rare but serious liver abnormalities LAMICTAL-rare but serious skin rash;"][/conditional]
[checkbox name="wellbutrin" value="Wellbutrin"]
[conditional field="wellbutrin" condition="(wellbutrin).is('Wellbutrin')"][textarea name="variable_3" default="insomnia, agitation, headaches, orthostatic hypotension, hypertension, seizures, rash (rare but serious); "][/conditional]
[checkbox name="APs" value="Antipsychotics"]
[conditional field="APs" condition="(APs).is('Antipsychotics')"][textarea name="variable_4" default="sedation, Parkinsonism, akathisia, akinesia, dystonia, tardive dyskinesia, blurred vision, dry mouth, constipation, urinary retention, metabolic syndrome, weight gain, neuroleptic malignant syndrome, stroke, cardiac arrest, priapism, respiratory suppression/aspiration, BLACK BOX WARNING: increased mortality in elderly;"][/conditional]
[checkbox name="lai" value="LAI Statement"]
[conditional field="lai" condition="(lai).is('LAI Statement')"][textarea name="variable_1wdsg68778ertret45hsg44rt3" default="**Long-acting injectable (LAI) antipsychotic medications improve overall patient outcomes and reduce caregiver burden by increasing compliance, reducing pill burden, decreasing relapse rates, maintaining more stable plasma concentration of the medication, and reducing hospitalizations.  Potential disadvantages include fewer dosage options compared to oral formulations, longer action leading to the potential for persisting side effects, and pain with injection.  The benefits outweigh the risks for this patient, and continued treatment with the LAI is the most appropriate treatment.***"][/conditional]
[checkbox name="remeron" value="Remeron"]
[conditional field="remeron" condition="(remeron).is('Remeron')"][textarea name="variable_5" default="agranulocytosis, sedation, QT-prolongation, serotonin syndrome, angle-closure glaucoma, increased appetite/weight gain, activation of mania/hypomania, elevated cholesterol/triglycerides, seizures, hyponatremia, and transaminitis; BLACK BOX WARNING: Increased risk of suicidal thoughts and behavior in pediatric and young adult patients taking antidepressants;"][/conditional]
[checkbox name="bzd" value="Benzos"]
[conditional field="bzd" condition="(bzd).is('Benzos')"][textarea name="variable_6" default="sedation, ataxia, memory loss, risk for dependence, abuse, and addiction, light-headedness, BLACK BOX WARNING: Concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. The continued use of benzodiazepines may lead to clinically significant physical dependence. The risks of dependence and withdrawal increase with longer treatment duration and higher daily dose. Abrupt discontinuation or rapid dosage reduction of benzodiazepines after continued use may precipitate acute withdrawal reactions, which can be life-threatening. To reduce the risk of withdrawal reactions, use a gradual taper to discontinue benzodiazepines or reduce the dosage;"][/conditional]
[checkbox name="anx" value="Hypnotics/Anxiolytics"]
[conditional field="anx" condition="(anx).is('Hypnotics/Anxiolytics')"][textarea name="variable_7" default="sedation, ataxia, paradoxical agitation, confusion, amnesia, addiction, respiratory suppression/aspiration, decreased motor skills, risk of falls; BLACK BOX WARNING FOR eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien, Ambien CR, Edluar, Intermezzo, and Zolpimist): increased risk for complex sleep behaviors including turning on ovens, driving cars, and shooting themselves with guns, hallucinations, and worsening depression or suicidality."][/conditional]
[checkbox name="li" value="Lithium"]
[conditional field="li" condition="(li).is('Lithium')"][textarea name="variable_8" default="GI upset, metallic taste, dizziness, increased appetite, fine tremor, polyuria, polydipsia, kidney damage, hypothyroidism BLACK BOX WARNING: toxicity;"][/conditional]
[checkbox name="tcas" value="TCAs"]
[conditional field="tcas" condition="(tcas).is('TCAs')"][textarea name="variable_9" default="dry mouth, blurred vision, constipation, sedation, urinary retention, impotence, tachycardia priapism, orthostatic hypotension; BLACK BOX WARNING: Increased risk of suicidal thoughts and behavior in pediatric and young adult patients taking antidepressants"][/conditional]
[checkbox name="stims" value="Stimulants"]
[conditional field="stims" condition="(stims).is('Stimulants')"][textarea name="variable_10" default="insomnia, agitation, headaches, GI upset, anorexia, hypertension, visual disturbances, irritability, seizures, blood dyscrasia BLACK BOX WARNING: addiction, psychosis;"][/conditional]
[checkbox name="achei" value="AChE Inhibitors"]
[conditional field="achei" condition="(achei).is('AChE Inhibitors')"][textarea name="variable_11" default="GI upset, muscle cramps, anorexia, orthostatic hypotension, syncope, seizures, GI bleeding;"][/conditional]
[checkbox name="nmda" value="NMDA Receptor Antagonists"]
[conditional field="nmda" condition="(nmda).is('NMDA Receptor Antagonists')"][textarea name="variable_12" default="dizziness, constipation, headaches, confusion."][/conditional]
[checkbox name="namzar" value="Namzaric"]
[conditional field="namzar" condition="(namzar).is('Namzaric')"][textarea name="variable_116uj" default="GI upset, muscle cramps, anorexia, orthostatic hypotension, syncope, seizures, GI bleeding, dizziness, constipation, headaches, confusion."][/conditional]
[checkbox name="traz" value="Trazodone"]
[conditional field="traz" condition="(traz).is('Trazodone')"][textarea name="variable_15" default="dizziness, fatigue, headache, hypotension, diarrhea, constipation, weight changes, blurred vision; BLACK BOX WARNING: Increased risk of suicidal thoughts and behavior in pediatric and young adult patients taking antidepressants "][/conditional]
[checkbox name="nued" value="Nuedexta"]
[conditional field="nued" condition="(nued).is('Nuedexta')"][textarea name="variable_16" default="thrombocytopenia, QT-prolongation with potential for TdP, hepatotoxicity, dizziness, constipation, urinary retention, diarrhea, cough, drowsiness, restlessness;"][/conditional]
[checkbox name="cogen" value="Cogentin"]
[conditional field="cogen" condition="(cogen).is('Cogentin')"][textarea name="variable_1w4rt3" default="Dry mouth, nausea, vomiting, blurred vision, urinary retention, hyperthermia, constipation, tachycardia, and anorexia;"][/conditional]
[checkbox name="busp" value="BuSpar"]
[conditional field="busp" condition="(busp).is('BuSpar')"][textarea name="variable_1w4rsdgt3" default="headaches, dizziness, nausea, dry mouth, fatigue, nonspecific chest pain, dream disturbances,  tinnitus, nasal congestion, RARE cogwheel rigidity and dystonic reactions;"][/conditional]
[checkbox name="clon" value="Alpha-2-Agonists"]
[conditional field="clon" condition="(clon).is('Alpha-2-Agonists')"][textarea name="variable_1wdsgh44rt3" default="sedation, hypotension, dry mouth, dizziness, bradycardia, HA, fatigue, and rebound hypertension if discontinued abruptly;"][/conditional]
[checkbox name="auvelity" value="Auvelity"]
[conditional field="auvelity" condition="(auvelity).is('Auvelity')"][textarea name="variable_1wdsgh44rt3" default="headaches, fatigue, ejaculatory delay, impotence, anorgasmia, GI distress, insomnia, agitation, orthostatic hypotension, hypertension, seizures, rash (rare but serious), BLACK BOX WARNING: Increased risk of suicidal thoughts and behavior in pediatric and young adult patients taking antidepressants;"][/conditional]
[checkbox name="cloz" value="Clozapine"]
[conditional field="cloz" condition="(cloz).is('Clozapine')"][textarea name="variable_1sgh4sdhgrt3" default="constipation, nocturnal enuresis, night-time sialorrhea, muscle stiffness, sedation, tremors, hyperglycemia, weight gain, risk for developing TD (lower than all other SGAs), retrograde ejaculation, and RARE periorbital edema; BLACK BOX WARNINGS: SEVERE neutropenia, orthostatic hypotension, bradycardia and syncope, seizures, myocarditis, and risk of death when used in elderly patients with dementia-related psychosis"][/conditional]
[checkbox name="val" value="VMAT-2 Inhibitors"]
[conditional field="val" condition="(val).is('VMAT-2 Inhibitors')"][textarea name="variable_1wdsgfdsg345h44rt3" default="sedation, QT-prolongation, anticholinergic effects, HA, N/V"][/conditional]
[checkbox name="prop" value="Beta Blockers"]
[conditional field="prop" condition="(prop).is('Beta Blockers')"][textarea name="variable_1wg345h4fs4rt3" default="nausea, diarrhea, cold extremities, bradycardia, hypotension, heart failure, heart block, fatigue, dizziness, insomnia, sexual dysfunction, alteration in glucose/lipid metabolism, vivid dreams/nightmares"][/conditional]
[checkbox name="aman" value="Amantadine"]
[conditional field="aman" condition="(aman).is('Amantadine')"][textarea name="variable_1wdsgertret45hsg44rt3" default="drowsiness, lightheadedness, rare NMS, psychosis, rare SI, rare disinhibited actions, xerostomia, rare SJS, can cause falsely elevated creatinine by up to 15%"][/conditional]
[checkbox name="MAOI" value="MAOIs"]
[conditional field="MAOI" condition="(MAOI).is('MAOIs')"][textarea name="variable_maoi" default="MAOIs are often effective in patients who have not responded to other antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). MAOIs require strict dietary restrictions to avoid tyraminerich foods (e.g., aged cheeses, cured meats, fermented foods) due to the risk of hypertensive crisis, which can be life-threatening. (THERE ARE NO DIETARY RESTRICTIONS FOR EMSAM</= 6mg/24 hours) Potential SEs: orthostatic hypotension, weight gain, sexual dysfunction, insomnia, edema.  RISK FOR HYPERTENSIVE CRISIS; RISK FOR SEROTONIN SYNDROME; BLACK BOX WARNING: Increased risk of suicidal thoughts and behavior in pediatric and young adult patients taking antidepressants; Long-term use of MAOIs may lead to tolerance and the need for dose adjustments, and there is potential for negative effects on liver function."][/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]
[comment memo="Use this GDR statement for antipsychotics used to treat agitation in dementia"]
Prescribed AP for 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]

[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]

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.
•The Supportive Care may function as a recommendation-only consultation service, and in those instances, the aforementioned recommendations are dependent upon the approval by the facility's medical director and implementation by facility staff.
•The resident or the resident's medical decision-maker gave informed consent to the recommended psychotropic drug regimen. Information was discussed regarding the resident's current psychiatric condition, the nature and purpose of the proposed treatment, including the risks of treatment vs. its benefits, alternatives to treatment including their risks and benefits, along with the risks of no treatment.  Education included BLACK BOX warnings and/or OFF-LABEL use, if applicable.

--PLAN--

•Condition #1 - [text name="variable_1avsdva" default=""]:
-[textarea name="variable_1234egrwdf" default=""]
•Condition #2 - [text name="variable_sdf4351" default=""]:
-[textarea name="variable_21345dfh1" default=""]
•Condition #3 - [text name="variable_sdf1544" default=""]:
-[textarea name="variable_34515gg" default=""]
•Condition #4 - [text name="variable_2wgfe" default=""]:
-[textarea name="variable_13etr547" default=""]

-F/U in [text name="f_u" default=""]

POC discussed with the pt, nursing, and the IDT.

[comment memo="FIRST CHECKBOX INCLUDES ALL INTERVENTIONS"]
NONPHARMACOLOGIC INTERVENTIONS:
[checkbox name="variable_12585562" value="-Slip-prevention/grippy socks, -Safety precautions per facility policies, -Keep door open, -Frequent visual checks, -Redirect/reorient often, -Provide the pt with their sensory assistive devices (glasses, hearing aids, etc...), -Maintain a bright and well-lit environment during the day and a dark and quiet environment at night, -Avoid sedative/hypnotic medications, -Provide the pt with objects to promote reminiscence, -Maintain as consistent of a schedule as possible, -Encourage the pt to participate in social activities, -Provide the pt with emotional support, -Use distraction as appropriate, -Assess for discomfort and unmet needs, -Frequently assess the pt for pain and treat as appropriate, -Ensure bed is in lowest position, -Reeducate the pt to rise slowly to prevent dizziness|-Slip-prevention/grippy socks|-Safety precautions per facility policies|-Keep door open|-Frequent visual checks|-Redirect/reorient often|-Provide the pt with their sensory assistive devices (glasses, hearing aids, etc...)|-Maintain a bright and well-lit environment during the day and a dark and quiet environment at night|-Avoid sedative/hypnotic medications|-Provide the pt with objects to promote reminiscence|-Maintain as consistent of a schedule as possible|-Encourage the pt to participate in social activities|-Provide the pt with emotional support|-Use distraction as appropriate|-Assess for discomfort and unmet needs|-Frequently assess the pt for pain and treat as appropriate|-Ensure bed is in lowest position|-Reeducate the pt to rise slowly to prevent dizziness"]

Staff to document:
[checkbox name="staff_doc" value="•Document any symptoms of DEPRESSION: i.e., excessive crying, refusals to eat, more withdrawal, feelings of despair, decrease in motivation, anger, difficulty in sleeping, mood swings, suicidal thoughts, hopelessness, helplessness, poor self-esteem, constant negativity.| 
•Document any symptoms of ANXIETY: i.e., inability to sit still, inability to sleep, excessive worry, extreme focus on self, nail-biting, shortness of breath, difficulty in concentrating, fear, pacing, yelling out, excessive call light use, demanding.| 
•Document any other PSYCHOTIC/BEHAVIORAL symptoms: i.e. hallucinations (tactile, visual, or auditory), delusions, paranoia, excessive motor activity, flight of ideas or racing thoughts, sexual inappropriateness, attempting to leave the facility, disrobing in public, hoarding, smearing or throwing food or feces, refusal of medications, refusals of ADL care."]

[checkbox name="delirium" value="Delirium Precautions:"]
[conditional field="delirium" condition="(delirium).is('Delirium Precautions:')"][textarea name="variable_104jk3" default="Non-Pharmacologic Guidelines for All Patients with Delirium (or at High-Risk for Delirium): 
• Promote Sleep-Wake Cycle 
o Cluster care to avoid repeated interruptions overnight 
o Review all care scheduled to occur at night and assess necessity (meds, vitals) and re-time if medically appropriate 
o Decrease noise in room and hallway as able 
o Open blinds in day, close at night 
o Lights off or soft lighting at night 
• Environmental Interventions 
o Provide a clear, safe passage to the bathroom 
o Limit causes of overstimulation – room changes, clutter, people in room, noise 
o Don’t hold rounds in room if not speaking directly to the patient 
o Institute fall precautions as appropriate 
o Provide as much consistency in staff and routine as possible 
o Provide glasses, hearing aids, dentures to decrease sensory impairment 
o Call light within reach 
o Remove lines/drains/catheters as soon as possible/safe 
• Communication Style 
o Approach patient in full view, give verbal warning before touching patient 
o Provide frequent re-orientation & reassurance of safety 
o Guide patient using one-step directions 
o If patient is argumentative, remain calm, try redirection but if not successful, do not confront 
§ Do a safety check, then leave room 
§ Return in 10 minutes to try again 
§ Upon return, start over and do not remind patient about previous interaction 
o Provide simple written information to be kept at bedside or signs (reminding patient where they are, how to use call light, not to get out of bed without assistance) 
• Family Involvement and Education 
o Seek family to describe patient’s baseline level of functioning and document in chart 
o Educate family about delirium including: 
§ Etiologies and management 
§ Waxing/waning course, possibility of hallucinations/delusions/confusion 
§ Communication style with patient (quiet environment & regular reassurance/reorientation) 
o Encourage family to stay with patient 
o Ask family to bring familiar objects from home (pictures, favorite blanket/pillow, pajamas, bedside items) 
o Refer to social work or psychiatric services for support 
• Promotion of and Restoration of ADL Independence 
o Use of PT/OT 
o Early mobilization with assistance (out of bed and into chair as often as possible, out of bed for meals, walks around unit if/when safe) 
o Oral hydration/nutrition as soon as able 
o Aspiration precautions 
o Scheduled toileting for urinary incontinence"][/conditional]

**Please note: This note may have been prepared using fluency direct voice recognition software. The transcription errors, when found, have been corrected. While every attempt is made to correct errors during dictation, errors may still exist.**
Add-on therapy?

Is the pt able to participate in the interview?


•PRESENT ILLNESS
--INTERVAL HISTORY--

This psychiatric visit was conducted The pt was evaluated, and privacy was secured and maintained.





Interview complicated?

If Psychiatric Exam is completely normal, make no changes below

•PHYSICAL EXAM
--PHYSICAL EXAM FINDINGS--

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

Psychiatric Exam:


--COLLABORATION--

Medical records, including H&P, hospital discharge/visit paperwork, PHQ-9, BIMS, ancillary services evaluations, most recent labs, and any other pertinent data in the EHR

The above-referenced documents were reviewed and noted. Coordination of care with nursing and social services staff was done to facilitate the best outcomes for the patient.

Any changes in the pt's medical condition, most recent vital signs, and relevant labs were noted.

Nursing staff, social services, activities director, registered dietician, nursing management, and other members of the IDT.

The pt’s history and psychiatric needs were discussed in detail to develop a plan of care to facilitate the best outcomes for the patient. Specific conversations are noted in the HPI or elsewhere in this note.

--ASSESSMENT--
is -year-old who was seen today for follow-up.

DSM-5-TR Diagnoses:
•Condition #1 - : Conditions entered here will appear in the PLAN section below
-
-
•Condition #2 - :
-
-
•Condition #3 - :
-
-
•Condition #4 - :
-
-

RISK-BENEFIT ANALYSIS



















































GDR indicated?


Use this GDR statement for antipsychotics used to treat agitation in dementia
Prescribed AP for dementia?






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.
•The Supportive Care may function as a recommendation-only consultation service, and in those instances, the aforementioned recommendations are dependent upon the approval by the facility's medical director and implementation by facility staff.
•The resident or the resident's medical decision-maker gave informed consent to the recommended psychotropic drug regimen. Information was discussed regarding the resident's current psychiatric condition, the nature and purpose of the proposed treatment, including the risks of treatment vs. its benefits, alternatives to treatment including their risks and benefits, along with the risks of no treatment. Education included BLACK BOX warnings and/or OFF-LABEL use, if applicable.

--PLAN--

•Condition #1 - :
-

•Condition #2 - :
-

•Condition #3 - :
-

•Condition #4 - :
-


-F/U in

POC discussed with the pt, nursing, and the IDT.

FIRST CHECKBOX INCLUDES ALL INTERVENTIONS
NONPHARMACOLOGIC INTERVENTIONS:


Staff to document:





**Please note: This note may have been prepared using fluency direct voice recognition software. The transcription errors, when found, have been corrected. While every attempt is made to correct errors during dictation, errors may still exist.**

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.58, 215 form elements, 454 boilerplate words, 27 text boxes, 46 text areas, 1 dates, 39 checkboxes, 5 radio buttons, 57 drop downs, 5 comments, 35 conditionals, 291 total clicks
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