Today, [checkbox name="variable_6" value="there is significant improvement|there are reports of  significant worsening of symptoms|there is no significant change in symptoms|there are some positive gains|symptoms have stabilized|symptoms    remain stable with current regimen"]. [textarea name="variable_162" default=""] 

Mood is [select name="variable_100" value="stable with no indications of depression or mania/hypomania|euthymic|depressed|anxious|irritable|labile|agitated|improving and showing positive response to regimen adjustments|unresponsive to changes in regimen"]. 
[checkbox name="assocsx" value="signs of manic/hypomanic episodes|irritability|negative self-perception|self-disparaging remarks|low interest and self-exclusion|feelings of hopelessness and worthlessness|irrational guilt|low energy and motivation|appetite disturbance|difficulties with comprehension due to ease of distraction|regular indecisiveness|poor confidence/self-esteem|sleep disturbance|mood-related hallucinations/delusions|psychomotor changes|gradiose thoughts|distractibility|increased    activity|pressured speech|increased energy|more social/outgoing|impulsive behaviors|loss of sleep|difficulty keeping up with thoughts|increased sex drive|spending|drugs/alcohol|risk-taking behaviors"].
[select name="variable_111" value="Consistent|Fair|Poor"] motivation; [select name="variable_134" value="is|is not"] engaging in interests and [select name="variable_678" value="no significant challenges|some difficulty|significant difficulty"] fulfilling responsibilities. 
[select name="variable_188" value="Socially active|Isolating|Improving social participation"]. 
[select name="variable_190" value="Consistent|Increased|Poor"] self-care/hygiene. 
[select name="variable_987" value="Less intense/frequent|Denies|Improving|Persistent"] rumination, excess worry. [select name="variable_512" value="Stable|Limited|Enhanced|Diminished|Poor"] capacity to cope with stressors effectively. [select name="panic" value="Denies|Hx of"] panic attacks. [select name="phob" value="Denies|Admits"] phobias/avoidance behaviors.
Attention, focus, concentration [select name="variable_567" value="stable|enhanced|decreased|poor"]. 
[select name="variable_671" value="Adequately|Difficulty"] fulfilling responsibilities. 
Sleeping [select name="variable_501" value="uninterrupted|interrupted"] [text name="variable_89" default=""]/night; attempts sleep [text name="variable_183" default=""], awakens [text name="variable_199" default=""]. 
Appetite is 
[select name="variable_349" value="healthy|fair regarding influence of mood symptoms|poor due to sx"]; [select name="variable_162" value="denies|exhibits"] weight changes. [select value="app1" value="Denies|History of|Admits"] irregular eating patterns.
[select name="SIHI" value="Denies active/passive ideation|Passive ideation, but no plan/intent or history of violence/impulsive behavior|Passive ideation with loose plan, but no intent or history of violence/impulsive behavior|Active ideation, but no plan/intent or history of violence/impulsive behavior|Active ideation with inconsistent plan, but no intent or history of violence/impulsive behavior"]; [select name="plan" value="no plan/intent or history of violence/impulsive behavior|plans are vague|plans are firm|plans are unviable|plans are lethal|plans are nonlethal|plans are undisclosed"] with [select name="ambiv" value="no ambivalence regarding suicide|ambivalence regarding suicide|expressed intention to die|expressed intention of suicide"] [textarea name="sihi" default=""]
Adhering to treatment plan. Receptive to safety planning. Denies other psychopathology, A/V/T/O hallucinations, delusions, disorganized thinking/behaviors, catatonia, recent substance/alcohol abuse, medication changes, or acute stressors. 
No new health concerns identified. 
Symptoms are [select name="variable_122" value="currently manageable|occasionally bothersome, but overall stable|distressing"]. [select name="seffects" value="Denies|Reports"] side effects. [text name="" default=""] [select name="variable_620" value="Denies need for changes at this time. Continue current tx regimen d/t stability|Will"] [textarea name="variable_102" default="adjust to target"]. Pt is agreeable. 

Currently prescribed: [text name="currmeds" default=""]

[select name="variable_1" value="Denies feeling|Can feel"] easily overwhelmed, tense/edgy; [select name="worry" value="no excess worries|tends to worry excessively"] and [select name="cope" value="stable|improving|limited"] capacity to cope with stressors efficiently. 

[checkbox name="atten" value="Stable; able to organize/prioritize and complete tasks without stress.|Difficulty organizing tasks/activities|avoids and procrastinates|forgetful|excessive talking/interrupting conversations|observable pattern of impulsive behavior|difficulty waiting/reduced patience|tendency toward addictive behaviors|inattentive daydreaming|chronic low self-esteem|difficulty with final details|short-tempered with outbursts/tantrums|stubborn, strong-willed|often disobedient|angry often|tendency to be immature|tendency to be or act irrational|trouble seeing someone else`s perspective|trouble with authorities|poor grades|poor school performance|trouble with math/numbers|not achieving up to potential|untended obligations|poor instructional follow through|chronic and problematic loss of items necessary for daily tasks|rushes through/messy work|often not completing work satisfactorily|difficulty negotiating differences|poor sense of responsibility|poor manager of money|spends excessive amount of time due to inefficiency"]

[checkbox name="anobed" value="Restriction of food intake in pursuit of weight loss|failure of weight gain with significantly low body weight|fear of gaining weight|distortion of self concepts|Forceful vomiting/purging after binge eating|fear of eating in public/with others|increased food intake in discrete time period|recurrent compensatory behavior to prevent weight gain|drinking excessive amount of water or non-caloric beverages|use of laxatives/diuretics/enemas|fasting, excessive exercise|stealing/hoarding food"] 

[select value="Denies obsessive/intrusive thoughts/mental rituals/urges.|Some recurring thoughts with repetitive behaviors, but no evoked distress or interference on daily living. No social isolation.|Endorses obsessive/intrusive thoughts/behaviors;|Continues to work on self-help strategies and lifestyle modifications to reduce interference on daily functioning.|Less interference on daily functioning due to coping/self-help strategies and lifestyle modifications."] [checkbox value="recurring thoughts/images|urges|repetitive behaviors|counting|focusing on geometry|checking|isolation|organizing/aligning objects|hoarding|fear of germs/illness|blinking|touching/tapping|needing constant reassurance|fear of dread|mental rituals|with excess time thinking/engaging in compulsions"]
[select value="ptsd2" value="Denies|Reports"] exposure to traumatic events. [textarea name="ptsd" default=""] [checkbox value="Denies reexperiencing/avoidance/arousal symptoms|Endorses associated intrusive memories/thoughts|nightmares|flashbacks|avoidance|negative affect|loss of interest|isolation|difficulty experiencing positive emotions|irritability/annoyance|risky/self-destructive behaviors|hypervigilance|heightened startle reaction"]
[checkbox value="Denies A/V/T/O hallucinations, delusions, disorganized thinking/behaviors. No catatonia.|Delusions of persecution|jealous delusions|somatic delusions|Grandiose delusions|religious delusions|thought broadcasting|thought insertion|Auditory hallucinations|Visual hallucinations|disorganized thoughts|disorganized behaviors|confusion"]. [text name="psychosis" default=""]
[checkbox value="No progression of difficulties in maintaining relationships, impulsivity, behavioral regulation, or affect regulation.|Hx of unstable relationships with others|idealizing and devaluing|identity disturbance|feelings of emptiness|affective lability|excessive anger|aggression|efforts to avoid abandonment|impulsive behaviors|suicidality|self injurious behavior|thrill seeking|paranoia|dissociation|attention seeking|abnormal 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|repetitive movements/speech|inflexibility/rigidity|restricted/fixated interests|alterations in sensorial reactivity"]. 

- NEUROLOGICAL: [select name="head" value="No|Reported"] history of concussion/head injury. [select name="seiz" value="No|Reported"] history of seizures.    [select name="migr" value="No|Reported"] migraines. [select name="msk1" value="No|Observed"] muscle weakness, abnormal/involuntary movements.    [select name="concen" value="Sustained attention|Difficulty sustaining concentration|Difficulty making decisions|mood instability|heightened anxiety|attention problems|troubled by hallucinations|fearfulness|nightmares|alcohol cravings|opiate cravings|headaches|weakness|disturbed sleep|repetitive movements/speech|inflexibility/rigidity|restricted/fixated interests|alterations in sensorial reactivity"]
- GI: [select name="weight" value="No|Notable"] weight changes. [checkbox value="Upset stomach|Nausea|Constipation|Heartburn|"Changes in bowel    habits|Sexual dysfunction"] [textarea memo="other" default="" rows="1"].
- All other systems reported negative or noncontributory.
Today, .

Mood is .
motivation; engaging in interests and fulfilling responsibilities.
rumination, excess worry. capacity to cope with stressors effectively. panic attacks. phobias/avoidance behaviors.
Attention, focus, concentration .
fulfilling responsibilities.
Sleeping /night; attempts sleep , awakens .
Appetite is
; weight changes. irregular eating patterns.
; with

Adhering to treatment plan. Receptive to safety planning. Denies other psychopathology, A/V/T/O hallucinations, delusions, disorganized thinking/behaviors, catatonia, recent substance/alcohol abuse, medication changes, or acute stressors.
No new health concerns identified.
Symptoms are . side effects.
. Pt is agreeable.

Currently prescribed:

easily overwhelmed, tense/edgy; and capacity to cope with stressors efficiently.

exposure to traumatic events.


- NEUROLOGICAL: history of concussion/head injury. history of seizures. migraines. muscle weakness, abnormal/involuntary movements.
- GI: weight changes.
- All other systems reported negative or noncontributory.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.79, 54 form elements, 131 boilerplate words, 6 text boxes, 5 text areas, 9 checkboxes, 33 drop downs, 1 comments, 193 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: