PRGN MED UPTD- NPNE

CC: [checkbox name="variable_cc" value="weekly medical progress note| daily medically-managed detox progress note (per protocol)"]

SUBJECTIVE:
[select name="variable_lastnamepronoun" value="Mr.|Ms.|Mx."] [text name="variable_ptname" default=""] is currently in residential treatment for [checkbox name="sud" value="alcohol use|amphetamine use|methamphetamine use|cannabis use|synthetic cannabis use|sedative use|benzodiazepine use|hypnotic use|anxiolytic use|stimulant use|opioid use|codeine use|heroin use|fentanyl use|oxycodone use|kratom use|phenibut use|crack use|xanax use|ativan use|cocaine use|adderall/vyvanse/ritalin use|hallucinogens use|MDMA use|Ketamine use|inhalants use|other psychoactive substances|polysubstance use"]
[checkbox name="medcc" value=". This patient denies any current subjective complaints or acute medical concerns|. This patient denies any ADR or side effects to medications|. This patient is not demonstrating any medically concerning, post-acute withdrawal symptoms|. There have been no reported complaints by nursing staff|. This patient has been medication adherent|. This patient has not been medication adherent|. This patient endorses any side effects to medications|. This patient endorses complaints of: "][textarea name="concerns" default=" "]. [select name="variable_1" value="|This patient is currently on a risk precaution:"][checkbox name="variable_1" value="fall risk| seizure risk| suicide risk|self-harm risk|AMA risk"].[checkbox name="variable_riskfs" value="This patient has not had any incidences regarding this risk factor."]
[checkbox memo="MEDICALLY-MANAGED DETOX SUBJ" name="If_detox1" value=""][conditional field="If_detox1" condition="(If_detox1).is('')"] 
This patient is currently undergoing a medically managed detox. This    patient is currently taking [checkbox name="variable_med1" value="librium|ativan|suboxone|diazepam|ativan PRN|oxazepam|gabapentin|tegretol|no medications"] for detox    symptoms. This patient is on taper day [text name="variable_tap" default=""][checkbox name="variable_detox2" value="This patient is not on a taper schedule"]. Withdrawal symptoms include [text name="variable_sx" default="anxiety"].[/conditional]

RECOVERY:  
- Depressive symptoms: Reported to be [select value="low|minimal|variable|medium|moderate|high|stable|present, but stable|present and unstable|unstable|stagnant|significantly better|somewhat better|somewhat worse|much worse|"].  [select value="||This could be attributed to|Current stability is attributed to|Current instability is attributed to  |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "] [checkbox value="continuation of current medications|recent medication changes|positive response to medications|lack of response to medications|situational stressors| situational stressors related to family|finanicial stressors|legal stressors|in-home stressors|in-facility stressors|home sickness|loneliness| grief|trauma|adjustment to the environment| incorporation of self-care|engaging with peers| engaging in individual therapy|engaging in group therapy|practicing coping skills|practicing TIPP skills|practicing STOP skills|practicing breathing excersise|lack of application of coping skills| lack of knowledge of coping skills|cravings for substances |abstaining from substance use|return to inpatient care|detox symptoms|post-acute withdrawal symptoms| decline in mental health|decline in physical health|improvement in mental health|improvement in physical health|changes in sleep patterns|lack of sleep|pain|upcoming discharge|unable to assess"]. [select name="variable_si" value="|Patient denies SI.| Patient endorses SI without plan or intent.| Patient endorses SI with plan.| Patient endorses self harming thoughts."]
- Anxiety symptoms: Reported to be [select value="low|minimal|variable|medium|moderate|high|stable|present, but stable|present and unstable|unstable|stagnant|significantly better|somewhat better|somewhat worse|much worse|"].  [select value="||This could be attributed to|Current stability is attributed to|Current instability is attributed to|Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "] [checkbox value="continuation of current medications|recent medication changes|positive response to medications|lack of response to medications|situational stressors| situational stressors related to family|financial stressors|in-home stressors|in-facility stressors| legal stressors|home sickness|loneliness| grief|trauma|adjustment to the environment| incorporation of self-care|engaging with peers| engaging in individual therapy|engaging in group therapy|practicing coping skills|practicing TIPP skills|practicing STOP skills|practicing breathing excersise|lack of application of coping skills| lack of knowledge of coping skills|cravings for substances |abstaining from substance use|return to inpatient care|detox symptoms|post-acute withdrawal symptoms| decline in mental health|decline in physical health|improvement in mental health|improvement in physical health|changes in sleep patterns|lack of sleep|pain|upcoming discharge|unable to assess"]. Anxiety is reported to be present [select value="occasionally.|mostly around situational stressors.|almost never.|about 50% of the time.|about 50-80% of the time.|most of the time on most days.|almost always.|"]
- Sleep is reported to be [select value="stable|unstable|stagnant|significantly better|somewhat better|somewhat worse|much worse|"]. [select value="|without any nightmares, interruptions, or dreams of substance use|This could be attributed to|Current stability is attributed to|Current instability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | with difficulties falling asleep| with difficulties with frequent awakenings|with difficulties staying asleep|with difficulties with nightmares|with difficulties with oversleeping"] [checkbox value="continuation of current medications|recent medication changes|lack of response to medications|positive response to medications|anxiety| legal issues|situational stressors|detox symptoms|lifestyle improvements|engaging in individual therapy|pain|upcoming discharge"][textarea].
- Focus: [select name="variable_f123" value=" Patient reports adequate focus during groups|Patient reports adequate focus during groups and with peers|Patient reports poor attention and concentration in conversations with peers and staff| Patient reports poor attention and concentration in groups|Patient reports difficulty concentrating throughout the day|Patient reports poor attention and concentration in groups|Patient reports having difficulty with memory|Unable to assess|Unable to assess due to poor group attendance"].
- Cravings: [select name="variable_cr" value="cravings are minimal due to being in a protected environment and manageable with coping skills|cravings are minimal due to being in a protected environment and manageable with coping skills and MAT|cravings are moderate due to both external and internal triggers"]
- Appetite: [select name="variable_ap" value="denies any changes or concerns with appetite|reports poor appetite| nutritionally deficient|reports flucuation in appetite| reports eating disorder disturbance|reports eating greater than 50% of each meal| reports eating less than 50% of each meal| reports bulimic episodes AEB vomitting after eating|reports restricting diet|reports eating snack and meals daily"]
This patient is [select name="variable_6" value="polite and cooperative|interactive|limited in their engagement with this conversation| polite, but has limited engagment in this conversation| withdrawn|guarded|hostile|questioning|demanding|agitated|anxious|tearful|manic presenting|dysregulated|dysthymic|euthymic|irritable"]. [select name="variable_time" value="Over this last week|Over the last 24 hours|Since admission"], this patient's progress can be characterized as [select name="variable_4225" value="making positive progress|declined in progress|stagnant|showing improvement|minimal|minimal due to resistance"] in learning to use coping skills to handle stress, anxiety, and modify habits.   
This patient benefits from this admission to a protected environment for medication management, education, and development of coping skills to prevent relapse.
[checkbox memo="Barriers/Strengths" name="bs" value=""]
[conditional field="bs" condition="(bs).is('')"][checkbox value="Barriers to success include: "][checkbox value="current apprehension to engage in psychopharmaceutical intervention|current apprehension to engage in structured psychotherapy|current substance use|limited social supports|dysfunctional interpersonal relationships"]. [checkbox value="Patient strength for success include: "][checkbox value="expression of willingness to engage in treatment recommendations|positive social supports|strong therapeutic rapport|daily medication compliance"][/conditional]

[checkbox name="variable_ccon" value="CO-MORBID CONDITION MONITORING UPDATES:|This patient has the following co-morbid condition that is being monitored"][remark memo="Replace word NUMBER with numeral in field names chrNUMBER, controlNUMBER, symptomsNUMBER, currenttxNUMBER, prevtxNUMBER, ptxNUMBER1, ptxNUMBER2, ptxNUMBER3, medtxNUMBER, MedSideEffectsNUMBER, dxreqNUMBER, SatisfiedNUMBER, OtherSpecsNUMBER, and OtherDetailsNUMBER "]
[checkbox memo="#NUMBER" memo_size="small" name="chrNUMBER" value="-Chronic Condition-"][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"][comment memo="-------------BEGIN CONDITION NUMBER-------------"][comment memo_size="small" memo_color="blue" memo="select one ▼▼"][frontload soapnote="sample/drgfms-include-condition-dropdown/"]
- [textarea memo="◀︎◀︎ and/or freetext" memo_size="small" memo_color="blue" rows="2" cols="50"]
 - Patient reports that the condition is [select name="controlNUMBER" value="well controlled|not well controlled|stable|unchanged from last visit|improved from last visit|worse than at last visit"]
 - Currently, [select name="symptomsNUMBER" value="the patient notes there are no symptoms.|symptoms are present including"][/conditional][conditional field="symptomsNUMBER" condition="(symptomsNUMBER).is('symptoms are present including')"] [checkbox value="pain|fatigue|shortness of breath|palpitations|nausea|vomiting|abdominal pain|urinary symptoms"][text default="."]
[/conditional][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"][checkbox name="currenttxNUMBER" memo="current treatment" value=""][/conditional][conditional field="currenttxNUMBER" condition="(currenttxNUMBER).is('')"] 
 - Current treatments include [select name="medtxNUMBER" value="no medications.|medications including "][/conditional][conditional field="medtxNUMBER" condition="(medtxNUMBER).is('medications including ')"][textarea]. [select name="MedSideEffectsNUMBER" value="The patient denies side effects|The patient complains of side effects including "][/conditional][conditional field="MedSideEffectsNUMBER" condition="(MedSideEffectsNUMBER).is('The patient complains of side effects including ')"][checkbox value="constipation|skin rash|diarrhea|diaphoresis|dizziness|drowsiness|dry mouth|headache|insomnia|nausea|suicidal thoughts|palpitations|anxiety|depression|malaise"][textarea cols="50" rows="2" memo_size="small" memo_color="blue" memo="◀︎◀︎ include more here."][comment memo_size="small" memo_color="blue" memo=" Add a space/comma/period in front, as appropriate, if any above are selected"].[/conditional][conditional field="currenttxNUMBER" condition="(currenttxNUMBER).is('')"] [select name="othertxNUMBER" value="No other treatments are noted.|Additional treatments include "][/conditional][conditional field="othertxNUMBER" condition="(othertxNUMBER).is('Additional treatments include ')"][textarea cols="50" rows="2"]. 
[/conditional][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"][checkbox name="prevtxNUMBER" memo="previous treatments" value=""][/conditional][conditional field="prevtxNUMBER" condition="(prevtxNUMBER).is('')"]
 -Previous treatments include [checkbox name="ptxNUMBER1" value="  -#1 - "][/conditional][conditional field="ptxNUMBER1" condition="(ptxNUMBER1).is('  -#1 - ')"][text size="60"], reason discontinued [checkbox value="intolerable side effects|no improvement"][textarea memo="other reason" memo_size="small" memo_color="blue"]
[/conditional][conditional field="prevtxNUMBER" condition="(prevtxNUMBER).is('')"][checkbox name="ptxNUMBER2" value="  -#2 - "][/conditional][conditional field="ptxNUMBER2" condition="(ptxNUMBER2).is('  -#2 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][textarea memo="other reason" memo_size="small" memo_color="blue"]
[/conditional][conditional field="prevtxNUMBER" condition="(prevtxNUMBER).is('')"][checkbox name="ptxNUMBER3" value="  -#3 - "][/conditional][conditional field="ptxNUMBER3" condition="(ptxNUMBER3).is('  -#3 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][textarea memo="other reason" memo_size="small" memo_color="blue"]
[/conditional][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"][checkbox memo="patient requests/needs diagnostic or lab tests" name="dxreqNUMBER" value=""][/conditional][conditional field="dxreqNUMBER" condition="(dxreqNUMBER).is('')"]
 - Patient [select value="needs|is due for|requests"] diagnostic testing including [comment memo_size="small" memo_color="blue" memo="select any number from below ▼▼"][checkbox value="CBC|CMP|Fasting Lipids|A1c|gout/uric acid labs|Thyroid labs|TSH|Free T4|Vitamin B12|Vitamin D|lupus labs|rheumatoid arthritis labs|lyme disease labs|RMSF labs|COVID-19 antibodies|COVID-19 nasopharyngeal swab|STI testing|X-ray|CT|MRI|Ultrasound"][textarea cols="50" rows="2" memo_size="small" memo_color="blue" memo="◀︎◀︎ include more here."][comment memo_size="small" memo_color="blue" memo=" Add a space/comma/period in front, as appropriate, if any above are selected"].
[/conditional][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"][checkbox memo="Other specialists comanage the condition" name="OtherSpecsNUMBER" value=""][/conditional][conditional field="OtherSpecsNUMBER" condition="(OtherSpecsNUMBER).is('')"]
 - Other specialists comanaging - [textarea rows="2" cols="50"][/conditional][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"][checkbox memo="Other details" name="OtherDetailsNUMBER" value=""][/conditional][conditional field="OtherDetailsNUMBER" condition="(OtherDetailsNUMBER).is('')"]
[textarea default=""][/conditional][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"][checkbox memo="Patient satisfied with treatment" name="PtSatisfied" value=""][/conditional][conditional field="PtSatisfied" condition="(PtSatisfied).is('')"]
- Pt [select name="SatisfiedNUMBER" value="|is|is not"] satisfied with current management[/conditional][conditional field="SatisfiedNUMBER" condition="(SatisfiedNUMBER).is('is not')"]; [text memo="details" size=60].[/conditional][conditional field="SatisfiedNUMBER" condition="(SatisfiedNUMBER).is('is')"].[/conditional][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"]
[comment memo="--------------END CONDITION NUMBER--------------"][/conditional]
____________________________________ 
Review/ Management:     
I reviewed the following information: medical hx, medications, allergies, physical exams and progress notes, V/S     
I obtained collateral information from: [checkbox name="variable_who" value="nursing|psychiatry|counselors|leadership"]
_________________________________________
ROS: Pertinent Neg and Pos discussed in HPI 
___________________________________________ 
OBJECTIVE:
[checkbox memo="MEDICALLY-MANAGED DETOX" name="If_detox" value=""][conditional field="If_detox" condition="(If_detox).is('')"] Detox progress:
- Current Medication includes: [checkbox name="variable_med1" value="librium|ativan|suboxone|diazepam|ativan PRN|oxazepam|gabapentin|tegretol|none"]
- Withdrawal scores:[text name="variable_wds" default=" CIWA/ COWS"]; [select name="variable_trend" value="|trend is waxing and wanning|trend is stagnant| trend is improving| trend is worsening"][/conditional]

Physical examination:    
[VSS and patient asymptomatic]    
Constitutional: cooperative, [select name="variable_general" value="in no acute distress|intoxicated|fatigue| anxious appearing| restless| agitated| guarded"], [select name="variable_3" value="well kempt|poorly kempt|appropriately dressed|inappropriately dressed|appropriately groomed|inappropriately groomed| appears stated age| appears older than stated age| appears younger than stated age| poor nutritional appearence| under-nourished| well-nourished"]   
Neuro: [select name="variable_neuro" value="A&O| A&Ox1|A&Ox2|A&Ox3|unable to determine|neurocognitive deficit seen| fatigue "] 
Respiratory: lung sounds clear, no accessory muscle use    
Cardiac: RRR, no m/r/g, [select name="variable_edema" value="no edema|+1 edema|+2 edema| pitting edema present"]  
GI: abdomen soft, non-distended, non-tender. Bowel tones normoactive
Psych: [select name="variable_8" value="calm and cooperative||calm|normal|upbeat|euthymic|depressed|dysthmic|neutral|anxious|hostile|irritable|tearful"] 

ASSESSMENT/PLAN:    
# Recovery 
Pt continues to benefit from admission in a protected environment to prevent relapse.   
Continue and Monitor:    
* Encourage to engage in group sessions, individual therapy sessions, and outings per treatment plan  
* Coordinate treatment with the psychiatric team  
* Encourage engagement in ongoing relapse prevention and aftercare plan    
* Continue to monitor recovery in a protected environment  
* [checkbox name="variable_labsadmit" value="Pending admission lab results to assess overall health status and guide treatment plan"]
* [checkbox name="variable_MATinfo" value="SUD craving medication:"] [select name="variable_MATnow" value="|none|still deciding|declined all options|naltrexone PO| naltrexone PO with subsequent vivitrol injection on discharge|acamprosate|not applicable|gabapentin|topirmate|naltrexone PO and acamprosate|naltrexone with subsequent vivitrol injection on discharge and campral| previously completed naltrexone| previously completed acamprosate| previously completed vivitrol|suboxone|suboxone with subsequent sublocade injection"] 
[checkbox memo="DETOX" name="If_detox2" value=""][conditional field="If_detox2" condition="(If_detox2).is('')"] # Detox
[textarea name="variable_detox22" default="- continue plan of care
- patient may attend outings at the discretion of the provider"][/conditional]
[checkbox memo="Admission Labs" name="labs" value=""][checkbox memo="MAT" name="mat" value=""]
[textarea name="medPOC" default=""]
[conditional field="labs" condition="(labs).is('')"]

# ADMISSION LABS  
- see progress note for interpretation 
- see PHI for lab results
- labs reviewed with patient[/conditional]

[conditional field="mat" condition="(mat).is('')"]
[select name="variable_1" value="# Medication-Assisted Treatment|# Cravings|choice C"]
The risk and benefits of this MAT medications have been explained to this patient. This patient has been provided education regarding this medication.
This patient would benefit from [checkbox name="variable_22" value="naltrexone|Vivitrol|acamprosate"].
[select name="variable_236" value="This patient declines MAT at this time| This patient accepts Naltrexone PO at this time|This patient accepts Naltrexone/ Vivitrol at this time| This patient is still deciding on MAT| This patient accepts acamprosate"] [/conditional]
CC:

SUBJECTIVE:
is currently in residential treatment for
. .
MEDICALLY-MANAGED DETOX SUBJ

RECOVERY:
- Depressive symptoms: Reported to be . .
- Anxiety symptoms: Reported to be . . Anxiety is reported to be present
- Sleep is reported to be .
.
- Focus: .
- Cravings:
- Appetite:
This patient is . , this patient's progress can be characterized as in learning to use coping skills to handle stress, anxiety, and modify habits.
This patient benefits from this admission to a protected environment for medication management, education, and development of coping skills to prevent relapse.
Barriers/Strengths



#NUMBER
____________________________________
Review/ Management:
I reviewed the following information: medical hx, medications, allergies, physical exams and progress notes, V/S
I obtained collateral information from:
_________________________________________
ROS: Pertinent Neg and Pos discussed in HPI
___________________________________________
OBJECTIVE:
MEDICALLY-MANAGED DETOX

Physical examination:
[VSS and patient asymptomatic]
Constitutional: cooperative, ,
Neuro:
Respiratory: lung sounds clear, no accessory muscle use
Cardiac: RRR, no m/r/g,
GI: abdomen soft, non-distended, non-tender. Bowel tones normoactive
Psych:

ASSESSMENT/PLAN:
# Recovery
Pt continues to benefit from admission in a protected environment to prevent relapse.
Continue and Monitor:
* Encourage to engage in group sessions, individual therapy sessions, and outings per treatment plan
* Coordinate treatment with the psychiatric team
* Encourage engagement in ongoing relapse prevention and aftercare plan
* Continue to monitor recovery in a protected environment
*
*
DETOX
Admission Labs MAT



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Sandbox Metrics: Structured Data Index 0.77, 138 form elements, 204 boilerplate words, 9 text boxes, 14 text areas, 42 checkboxes, 33 drop downs, 6 comments, 1 remarks, 32 conditionals, 1 frontloads, 297 total clicks
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