Office Intake

[text name="name" memo="Patient name" size="20"] is a [text memo="age" size="2"]-year-old, [text memo="ethnicity" size="20"],[checkbox value="single|married|divorced|partnered"][checkbox value="cis-gender female|cis-gender male|transgender female|transgender male|gender non-binary individual"][text memo="other gender" value="20"] 
[var name="name"] that [select value="presents via telehealth|presents in this outpatient appointment "][select value="alone|with family |with significant other |with DHHS worker |with case manager |by police|"][text memo="names" size="20"][select value=" for evaluation and management of | due to reports of |"][text memo="presenting problem" size="20"]. [select value="The patient reports |The family reports |The Guardian reports |The case manager reports |Electronic records indicate |Police report indicates |"][select value="a past history of |no history of mental health concerns until |no history of mental health concerns|"]
[textarea memo="Mental health history" rows="5"]. [checkbox name="depression" memo="depression" value=""][checkbox name="anxiety" memo="anxiety" value=""][checkbox name="sleep" memo="sleep" value=""][checkbox name="mood" memo="mood" value=""][checkbox name="ptsd" memo="ptsd" value=""][checkbox name="adhd" memo="adhd" value=""][checkbox name="autism" memo="autism" value=""][conditional field="depression" condition="(depression).is('')"]
[var name="name"]'s depression is characterized as [checkbox value="little interest or pleasure in doing things|hopelessness|helplessness|sleeping too much|difficulty getting to sleep|difficulty staying asleep|feeling tired or having little energy|poor appetite|overeating|feelings of inadequacy|irritability|poor concentration|psychomotor retardation|psychomotor agitation|suicidal ideation"]. [select value="Depressive symptoms are present most of the day, nearly every day|Depressive symptoms are mostly present |"][text size="20"][select value=", are exacerbated by |"][text size="20][select value=", are improved by |"][text size="20]. [select value="Depressive symptoms impact|"][select value=" social/work functioning by | "][textarea rows="1"].
Client rates depression [select value="1|2|3|4|5|6|7|8|9|10"]/10 with 10 being the worst.[textarea memo="Additional Depression information" rows="5"][/conditional]

[conditional field="anxiety" condition="(anxiety).is('')"]
[var name="name"]'s anxiety generally presents as [checkbox value="feeling nervous or on edge|worry|difficulty relaxing|feeling restless|difficulty getting to sleep|difficulty staying asleep|irritability|poor appetite|overeating"][text size="20]. [select value="Anxiety is present |"][select value="in the context of multiple different situations/events such as |primarily in social situations such as | "][textarea rows="1"]. [select value="Anxiety usually last for approximately |Anxiety is present most of the time on most days"][text size="20"][select value=", is brought on by |"][text size="20][select value=", is relieved by |"][text size="20]. Client rates anxiety [select value="1|2|3|4|5|6|7|8|9|10"]/10 with 10 being the worst. [textarea memo="Additional Anxiety information" rows="5"][/conditional][conditional field="mood" condition="(mood).is('')"]

[select value=" Mood instability has been an issue since |"][text size="20"]. [select value="Disordered mood can present as |"][checkbox value="euphoria|excessive energy|excessive self-confidence|insomnia|irritability|agitation|racing thoughts|impulsive behavior|risk taking behavior|paranoia|delusions of grandeur|auditory hallucinations|visual hallucinations|depression|apathy|hopelessness|helplessness|suicidal thoughts|no motivation|hypersomnia"]. [select value="Mood lability is exacerbated by |There are no identified precipitating factors to mood lability|"][textarea rows="1"]. [textarea memo="additional information of mood lability" rows="4"][/conditional][conditional field="autism" condition="(autism).is('')"]

[select value="Per patient,|Per family,|Per record,|"][text size="20"][select value=" they have been | patient has been |"][select value="diagnosed|undiagnosed|"][text size="20"][select value=" autism spectrum disorder "][textarea memo="details of diagnosis/symptom timeframe" rows="4"]. [var name="name"]'s symptoms present as persistent difficulty, in multiple contexts, with social communication and interaction including: [checkbox value="abnormal or failed back and forth conversation|failure to initiate or respond to social interactions|reduced sharing of interests/emotions|limited emotional affect|limited/incongruent nonverbal communication|difficulty with developing/maintaining/understanding relationships|difficulty sharing imaginative play|limited or absent interest in peers"]. They have demonstrated restricted/repetitive patterns of behavior, interests, or activities including: [checkbox value="repetitive motor movements|repetitive speech|infexible adherence to routines|ritualized patterns of verbal or nonverbal behavior|significant difficulty with transitions|rigid thinking patterns|highly restricted and fixated interests|hyper-reactivity to sensory input|hyporeactivity to some sensory input"]. Presentation is [select value="without|with"] intellectual impairment, and [select value="without|with"] language impairment. [textarea rows="4"][/conditional][conditional field="adhd" condition="(adhd).is('')"]

[var name="name"] has a pattern of [checkbox name=addtype value="inattention and hyperactivity/impulsivity|inattention|hyperactivity/impulsivity"] that interferes with functioning. [/conditional][conditional field="addtype" condition="(addtype).is('inattention and hyperactivity/impulsivity')||(addtype).is('inattention')"] Inattention manifests as [checkbox memo="At least 6 for ADHD" value="poor attention to details or careless mistakes in work or activities|difficulty sustaining attention|not seeming to listen when spoken to directly|not following through on instructions or failing to finish tasks|having difficulty organizing tasks and activities|avoiding tasks that require sustained mental effort|frequently losing things necessary for tasks|often easily distracted by extraneous stimuli|forgetfulness in daily activities"].[/conditional] [conditional field="addtype" condition="(addtype).is('inattention and hyperactivity/impulsivity')||(addtype).is('hyperactivity/impulsivity')"] [var name="name"]'s hyperactivity/impulsivity presents as [checkbox memo="six or more for ADHD" value="frequent fidgeting or squirming|often leaving seat when remaining seated is expected|frequently restless|difficulty engaging in leisure activities quietly|often seeming to be on the go or difficult to keep up with|excessive talking|blurting out answers before a question has been completed|difficulty waiting for their turn|interrupting or intruding on others"].[/conditional][conditional field="adhd" condition="(adhd).is('')"] These symptoms have been present since [text memo="before 12yo" size="20"], and are recognized in multiple settings including [text memo="2 or more" size="20"]. [textarea rows="3"]

[/conditional][conditional field="sleep" condition="(sleep).is('')"]
Sleep is reported to be generally [select name="sleepq" value="poor |fair |good.|erratic |inconsistent |excessive|"][select value="with difficulty initiating sleep and staying asleep due to |with difficulty initiating sleep due to |with difficulty maintaining sleep due to |"][textarea rows="2"]. They estimate getting approximately [text size="4"] hours of [select value="broken |solid |"]sleep per night. [select value="Disturbed sleep has been an issue for |Disturbed sleep is a new issue within the last |"][textarea rows="1"]. [select value="There has been no workup for Sleep Apnea|There was a past workup for sleep apnea which indicated |"][textarea rows="1"]. [select value="Current attempts at improving sleep include |The patient is currently attempting no interventions to improve sleep|Current quality of sleep is dependent on |"][textarea rows="2"]. [select value="Past unsuccessful attempts at improving sleep include |There have been no past attempts at improving sleep|"][textarea rows="2"]. [/conditional]
Risk Assesment:
[select value="They are not currently receiving individual counseling/therapy|They are currently engaging in individual counseling with |"][textarea rows="1"].
[select value="They deny current suicidal ideation or thoughts of self harm|They report positive for |They deny suicidal ideation but state having thoughts of being better off dead"][textarea rows="1"].[select value="They deny having access to guns|They report positive for having guns in the home |"][textarea rows="1"]. [checkbox value=" Explained that we ask this question because guns in the home increase the risk of suicide, homicide and accidental death, Provided education about the importance of keeping guns locked and separated from ammunition. Explained that should this provider feel that patient is unsafe to self or others, provider and patient will work together to develop a safe place to keep weapons to decrease risk of impulsive suicide or homicide."]

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 name="c" value="Steady gait while walking, normal strength bilaterally|"][conditional field="c" condition="(c).is('')"]
[checkbox value="steady gait while walking|unsteady gait while walking|clumsy|unable to ambulate|in bed|in wheelchair|assisted by cane|assisted by walker|rigid|spastic|normal strength bilaterally|weakness noted in "][/conditional][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"][conditional field="b" condition="(b).is(' with psychotherapy')"]
[comment memo="Psychiatric Add On
Psychotherapy/Interactive Complexity/Prior case management
"][checkbox value="Time spent in psychotherapy: "][checkbox value="16-37 min"][comment memo="30 min 90833"][checkbox value="38-52 min"][comment memo="45 min 90836"][checkbox value="53-67 min"][comment memo="60 min 90838"]
[checkbox value="Focus of psychotherapy: "][checkbox value="interpersonal conflict|emotional experience related to diagnosis|identification of coping mechanisms|grief counseling"][textarea memo="other" default="" rows="1"]
[checkbox value="Modality: "][checkbox value="insight oriented|supportive|behavioral modification"][textarea memo="other" default="" rows="1"][/conditional]

Neurological - [checkbox value="Headaches|weakness|disturbed sleep|denied"][textarea memo="other" default="" rows="1"]
GI - [checkbox value="Upset stomach|nausea|constipation|heatburn|denied"][textarea memo="other" default="" rows="1"]
All other systems negative

Patient is currently displaying [select value="symptoms of|well managed|moderately managed|poorly managed"] [checkbox value="depression|anxiety|sleep disturbance|psychosis|substance abuse|cognitive impairment|impulsivity|mood lability|alcohol dependence|opiate 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 ADHD|their cancer treatment|their depressive disorder|their  anxiety disorder|their bipolar disorder|interpersonal/family conflict|current psychopharmaceutical intervention|current psychotherapy|current psychosocial support systems"][textarea memo="other" default="" rows="1"].  Patient would  benefit from [checkbox value="initiation of psychopharmaceutical intervention|continued psychopharmaceutical intervention|adjustments to current psychopharmaceutical intervention|initiation of psychotherapy|continuation of current psychotherapy|engaging in grief therapy|engaging in CBT|engaging in family therapy|enhanced psychosocial supports|increasing personal time and self-care"]. Prognosis is [select value="good|fair|poor"] considering the patient [select value="remains adherent to|actively engages in"] medication and 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 psychopharmaceutical intervention|current apprehension to engage in structured psychotherapy|current emotional distress of recent cancer diagnosis|limited social supports|dysfunctional interpersonal relationships"][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"][textarea memo="strengths" rows="1"].  [textarea rows="5"]

[conditional field="A" condition="(A).is('Followup')"]*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"][/conditional]
*Data Reviewed*
[conditional field="A" condition="(A).is('Followup')"][comment memo="1pt each, 2pt for summary"][/conditional][checkbox value="I reviewed the following notes:"][textarea default="" rows="1"][conditional field="A" condition="(A).is('Followup')"][comment memo="
1pt each, 2pts for summary"][/conditional][checkbox value=" I reviewed the following labs, imaging, consults: "][textarea default="" rows="1"][conditional field="A" condition="(A).is('Followup')"][comment memo="
1pt each, 2pts for summary"][/conditional][checkbox value=" I obtained collateral information from "][textarea default="" rows="1"][conditional field="A" condition="(A).is('Followup')"][comment memo="
2pts each"][/conditional][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"]
*Management*[conditional field="A" condition="(A).is('Followup')"][comment memo="
Low (99213)= One stable chronic illness/Two or more self-limited or minor problems
Moderate (99214)= Prescription meds; chronic illness with mild exacerbation or side effects of treatment; 2 or more stable chronic illnesses
High (99215)= Psychiatric illness with potential threat to self or others, drug therapy requiring intensive monitoring for toxicity; one or more chronic illnesses with severe exacerbation, progression, or side effects of treatment"][/conditional]
The following interventions were ordered/recommended this appointment:
[textarea rows="5"] [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. "]Diagnosis:[conditional field="A" condition="(A).is('Followup')"][comment memo="Indicate whether diagnosis changed, reason for change, date and time of change
"][/conditional][checkbox value="Major depressive disorder|recurrent|single episode|mild|moderate|severe|Bipolar II|Depression|Manic|hypomania|Mixed|without psychosis |with psychosis|Generalized anxiety disorder|PTSD |acute|chronic|ADHD |inattentive type|hyperactive type|mixed|Adjustment Disorder|with depressed mood|with anxiety|with depressed mood and anxiety"]
[textarea rows="5"]

[textarea rows="3"]

I,Keife Earley PMHNP-BC, personally examined the client obtained a history, conducted a mental status examination of the patient, and developed the plan of care.
Patient name is a age-year-old, ethnicity, other gender
name that namespresenting problem.
Mental health history. depression anxiety sleep mood ptsd adhd autism

Risk Assesment:

Appearance: , other.
Gait and Station / Muscle Strength and Tone: other.

Fund of Knowledge: Based on the answers to interview questions, patient's intelligence is judged to be other

Neurological - other
GI - other
All other systems negative

Patient is currently displaying other which is other. Patient would benefit from . Prognosis is considering the patient medication and therapy to address target of treatment . barriers. strengths.


*Data Reviewed*
individual and reason for consultation
The following interventions were ordered/recommended this appointment:


I,Keife Earley PMHNP-BC, personally examined the client obtained a history, conducted a mental status examination of the patient, and developed the plan of care.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.6, 183 form elements, 103 boilerplate words, 19 text boxes, 40 text areas, 45 checkboxes, 44 drop downs, 6 variables, 11 comments, 18 conditionals, 315 total clicks
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