Peoria Post Acute Soap note follow up Shawna

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

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

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

Patient is observed [checkbox value="Sitting in wheelchair |in the hall|in their room|Lying in bed|sitting in bed|in common area|eating their meal|interacting with peers|interacting with staff|watching television "][textarea memo="other" default=" " rows="1"] [select value="A&O|A&O x 1|A&O x 2|A&O x 3|A&O x 4|Alert|Drowsy|Lethargic|Sleeping, arousable|Alert and oriented with appropriate responses|Disoriented|UTA|"] [text size="14"] [checkbox value="Patient is able to engage in evaluation|Patient is unable to engage in evaluation"][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|uncooperative|Presents irritable|Presents agitated"] [text size="14"][textarea memo="HPI" default="Reports" cols="38" rows="2"] [checkbox value="Rates 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="Rates 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 "] [select value="|good.|fair.|poor.|"][textarea memo="appetite" default="" cols="20" rows="1"] [checkbox value="Reports sleep is"] [select value="|good.|fair.|poor.|"][textarea memo="sleep" default="" rows="1"] [checkbox value="Denies |auditory or visual hallucinations|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 frequent 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: [select value="low risk of acute dto or dts|high risk of acute dto or dts|"][text memo="risk" size="30"]
MEMORY/CONCENTRATION/COGNITION: [select value="Intact|Forgetful|Disoriented|Impaired|UTA"] [text size="14"]
SPEECH: [select value="normal rate, tone, volume|slow rate|rapid speech|low volume|loud volume|non verbal|UTA"][select value="|, slow rate|, rapid speech|, low volume|, loud volume|, non verbal|UTA"] [text size="14"]
THOUGHT PROCESS AND CONTENT: [select value="Intact, Linear W/O disorder|logical, Goal-Directed|illogical at times|Paranoia| Delusions|disorganized|tangential|UTA|"] [select value="|Intact, Linear W/O disorder|logical, Goal-Directed|illogical at times|Paranoia|Delusions|disorganized|tangential|UTA"] [text size="14"]
INSIGHT and JUDGMENT: [select value="Intact|Good|Fair|Poor|UTA"] [text size="14"]
AFFECT: [select value="|Neutral|constricted|labile|flat|tearful|Euthymic|Depressed|Manic|Angry|Anxious|UTA"] [select value="|Euthymic|smiling|Depressed|Neutral|Manic|Angry|Anxious|, Not appropriate|, Blunted|, Flat|, Labile|, irritable|, tearful"][textarea name="other" default=" " rows="1"]
MOOD: [select value="Euthymic|Irritable|agitated|depressed|elevated|Neutral|Manic|Angry|Anxious|UTA"] [select value="|Euthymic|Irritable|agitated|depressed|elevated|Neutral|Manic|Angry|Anxious|UTA|"][textarea name="other" default=" " rows="1"]
[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="Encourage 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."]