PEORIA POST ACUTE PQ

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

PATIENT NAME: [textarea memo="NAME/room#/AGE/ETHNICITY" default=" " rows="1"]
meds: [textarea memo="meds" default=" " rows="2"]

CC: Patient is a [checkbox name="variable_6" value="male|female|transgender"] client being seen for [select value=" follow up on | new psychiatric consultation. |Depression|Anxiety|Bipolar|Schizoaffective|Behavioral Disturbances|Dementia|Psychosis|Insomnia|Agitation|PTSD|Trichotillomania"][select value="| Depression|Anxiety|Bipolar|Schizoaffective|Behavioral Disturbances|Dementia|Psychosis|Insomnia|Agitation|PTSD|Trichotillomania"][select value="|, Depression|, Anxiety|, Bipolar|, Schizoaffective|, Behavioral Disturbances|, Dementia|, Psychosis|, Insomnia|, Agitation|, PTSD|, Trichotillomania"][select value="||, Depression|, Anxiety|, Bipolar|, Schizoaffective|, Behavioral Disturbances|, Dementia|, Psychosis|, Insomnia|, Agitation|, PTSD|, Trichotillomania"][text memo="cc" default=" " size="18"]

Patient is observed [checkbox value="sitting up in bed|lying in bed|sitting in wheelchair|in their room|in the hall|in common area|watching television.|eating their meal.|interacting with peers.|interacting with staff."][textarea memo="other" default=" " rows="1"] [checkbox value="Patient is able to engage in evaluation.|Patient is unable to engage in evaluation."][text size="14"] [checkbox value="Alert and oriented with appropriate responses.|A&O.|A&O x 1.|A&O x 2.|A&O x 3.|A&O x 4.|Alert.|Drowsy.|Lethargic.|Sleeping, arousable.|Disoriented."] [text size="14"] [checkbox value="Responds appropriately.|Responds inappropriately."] [text size="14"] [checkbox value="Able to make needs known, no distress noted.|Unable to verbalize needs."] [text size="14"] [checkbox value="Presents calm, cooperative, and pleasant.|Presents as uncooperative.|Presents as irritable.|Presents as agitated."] [text size="14"][checkbox value="Reports"][textarea memo="HPI: REPORTS" default="" cols="38" rows="2"] [checkbox value="Reports depression as"] [select value="|none.|mild.|moderate.|high.|0/10.|1/10.|2/10.|3/10.|4/10.|5/10.|6/10.|7/10.|8/10.|9/10.|10/10.|same.|improved.|worsened.|declined to answer.|UTA, nonverbal."] [textarea memo="depression" default="" cols="20" rows="1"] [checkbox value="Reports anxiety as "] [select value="|none.|mild.|moderate.|high.|0/10.|1/10.|2/10.|3/10.|4/10.|5/10.|6/10.|7/10.|8/10.|9/10.|10/10.|same.|improved.|worsened.|declined to answer.|UTA, nonverbal."] [textarea memo="anxiety" default="" cols="20" rows="1"] [checkbox value="Reports appetite is "] [checkbox value="good.|fair.|poor."][textarea memo="appetite" default="" cols="20" rows="1"] [checkbox value="Reports sleep is"] [checkbox value="good.|fair.|poor."][textarea memo="sleep" default="" cols="20" rows="1"] [checkbox value="Denies AH/VH/SI/HI/DTO/DTS/paranoia, delusions, or psychosis"] [checkbox value="Denies |auditory hallucination|visual hallucinations|suicidal ideation|homicidal ideation|DTO/DTS|thoughts of self-harm or self-injury behaviors|thoughts of harm to others|Denies S/S of paranoia, delusions, or psychosis"] [checkbox value="Denies racing thoughts.|No concerns reported by staff."] [textarea memo="other" default="" rows="1"] [checkbox value="Reports being stable on current medication regimen|Reports being unstable on current medication regimen."] [checkbox value="Denies having any new concerns or questions.|Patient was provided support and therapeutic listening to reduce depression.|Patient was provided support and therapeutic listening to reduce anxiety.|Patient showing improvement with recent medication adjustments."] [textarea memo="Comments" default="" rows="1"]

Assessment of overall level of risk: [checkbox value="low risk of acute dto or dts|high risk of acute dto or dts"][text memo="risk" size="30"]
APPEARANCE: [checkbox value="normal|comfortable|uncomfortable|relaxed|well-groomed|well-kempt|appears their stated age|unkempt|disheveled|appears younger than stated age|appears older than stated age"][text size="14"]
POSTURE: [checkbox value="normal|relaxed|slumped|rigid|tense|atypical|uta"][text size="14"]
EYE-CONTACT: [checkbox value="average|intermittent|avoidant|intense|eyes closed|eyes closed while talking|uta"][text size="14"]
MEMORY/CONCENTRATION/COGNITION: [checkbox  value="Intact|Forgetful|Disoriented|Impaired|UTA"] [text size="14"]
SPEECH: [checkbox value="normal rate, tone, volume|slow rate|rapid speech|low volume|loud volume|non verbal|mouths words|stuttering|UTA"] [text size="14"]
THOUGHT PROCESS AND CONTENT: [checkbox  value="intact|linear W/O disorder|logical, goal-directed|illogical at times|paranoia|delusions|flight of ideas|disorganized|rambling|tangential|word salad|incoherence|UTA"]  [text size="14"]
INSIGHT and JUDGMENT: [checkbox value="Intact|Good|Fair|Poor|UTA"] [text size="14"]
AFFECT: [checkbox  value="neutral|full|constricted|labile|flat|tearful|euthymic|depressed|manic|angry|anxious|not appropriate|blunted|irritable|tearful|uta"] [textarea name="other" default=" " rows="1"]
MOOD: [checkbox  value="euthymic|irritable|agitated|depressed|elevated|neutral|manic|angry|anxious|UTA"] 
[textarea default=" " rows="2"]

PLAN:[textarea memo="*Med change" default=" " rows="1"] [checkbox value="Continue medication as prescribed, no changes made at this time."] [checkbox value="Provide assessment, therapeutic listening, and medication management to reduce psychiatric symptoms."] [checkbox value="Patient declined Psychotherapy."] [checkbox value="Plan is to continue psychiatric medication due to chronicity of symptoms and established diagnosis."] [checkbox value="Medication continuation warranted to continue psychiatric stability."] [checkbox value="Lowest effective doses pursued."] [checkbox value="Follow up to assess for negative behaviors, medication efficacy and supportive therapy."] [checkbox value="GDR has not been attempted and is currently not recommended.|GDR has been attempted."] [checkbox value="Encouraged therapy to address symptoms."] [checkbox value=" Provide safe and therapeutic milieu."] [checkbox value="Discussed and reviewed importance of pt calling for staff with call light, not getting out of bed without assist from staff. Pt confirmed understanding and agreement."]