Progress fast

HISTORY OF PRESENTING PROBLEM[conditional field="A" condition="(A).is('Followup')"][comment memo="
99212 requires 1 HPI
99213 requires 1 HPI + pertinent ROS
99214 requires 4 HPI + pertinent ROS plus one other + 1 P/F/S hx
99215 requires 4 HPI + complete ROS + 2 P/F/S hx"][/conditional][conditional field="A" condition="(A).is('Intake')"][comment memo="
Intake = 90792"][/conditional]
[conditional field="A" condition="(A).is('Intake')"][/conditional]
The patient is a [text name="variable_1" default=""] year old [checkbox name="variable_1" value="male |female |non-binary"] who presents to the clinic for [checkbox name="variable_1" value="an inital psychotherapy intake|follow-up psychotherapy appointment"]. The patient has a diagnosis of [checkbox name="variable_1" value="anxiety disorders |depression disorders |personality disorder | schizophrenia | attachment disorder | sleep disturbances | Bipolar | OCD | ADHD/ADD | PTSD | Eating disorder | mood disorder"].
The Patient remains [comment memo="SYMPTOM"][checkbox value="depressed|anxious|aggressive|impulsive|inattentive|irritable|withdrawn|unable to sleep|delusional|auditory hallucinations|visual hallucinations"][textarea memo="other" default="" rows="1"].
Which is described as[comment memo="SEVERITY "][checkbox value=" the same as it has been| better| somewhat worse than it has been| significantly worse than it has been"][textarea memo="other" default="" rows="1"]
The patient notices that it is sometimes improved by [comment memo="Modifying factors "][checkbox value="talking to someone|being alone|doing something physical like walking|doing something that is distracting"][textarea memo="other" default="" rows="1"]

Mental Status Examination:
General: [select name="variable_2" value="alert and oriented in all spheres|obtunded|disoriented"].
Appearance: [select name="variable_3" value="well kempt|poorly kempt|appropriately dressed|inappropriately dressed|appropriately groomed|inappropriately groomed"].
Behavior - general: [select name="variable_4" value="in no acute distress|in acute psychological distress"].
Behavior - stability: [select name="variable_5" value="calm|agitated"].
Behavior - interactivity: [select name="variable_6" value="warm with comments and behavior|interactive|withdrawn"].
Behavior - eye contact: [select name="variable_7" value="eye contact good|eye contact fair|eye contact avoidant"].
Mood/Affect - stated: [select name="variable_8" value="normal|upbeat|euthymic|depressed"].
Mood/Affect - emotional range: [select name="variable_9" value="normal|broad|restricted"].
Mood/Affect - intensity: [select name="variable_10" value="normal|expansive|blunted|flat"].
Mood/Affect - congruence: [select name="variable_11" value="mood is congruent with affect|mood and affect are not congruent"].
Thought form and content: [select name="variable_12" value="normal|future oriented|logical, linear and goal-oriented|past oriented and somber|goal directed|scattered|hopeful|remorseful|enthusiastic|resigned"]
Attention: [select name="variable_13" value="no difficulty with attention or concentration|had some attentional and concentration problems during the exam"].
Perception - insight: [select name="variable_14" value="normal insight|poor insight"]
Perception - general: [select name="variable_15" value="normal|hallucinations - auditory|hallucinations - auditory, talking to someone not present|hallucinations - visual|hallucinations - visual - looking at something not present|hallucinations - multiple"]
Cognition/Memory: [select name="variable_16" value="normal|grossly intact|below average|above average"].
Cognition/Memory - abstraction: [select name="variable_17" value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"]
Judgment: [select name="variable_18" value="normal|poor|good"].
Suicide/Assault: [select name="variable_19" value="no current or past ideation or intent|denies an active sense of wanting to harm self or others|present but without intent or plan|resolved"].
Patient is currently assessed to be at [select name="variable_20" value="low|moderate|high"] risk for self harm or harm to others as evidenced by ideation and behavior on today's exam.

Diagnosis:
[checkbox name="variable_1" value="anxiety disorders |depression disorders |personality disorder | schizophrenia | attachment disorder | sleep disturbances | Bipolar | OCD | ADHD/ADD | PTSD | Eating disorder | mood disorder"]. 

Assessment:
Focus of psychotherapy: [checkbox value="interpersonal conflict|emotional experience related to diagnosis|identification of coping mechanisms|grief counseling"][textarea memo="other" default="" rows="1"]
Modality: [checkbox value="insight oriented|supportive|behavioral modification"][textarea memo="other" default="" rows="1"]
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 unmanaged depressive disorder|their unmanaged anxiety disorder|their unmanaged 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="continuation of current psychotherapy |enhanced psychosocial supports|increasing personal time and self-care|continued psychopharmaceutical intervention|adjustments to current psychopharmaceutical intervention|engaging in grief therapy|engaging in CBT|engaging in family therapy"][textarea memo="other" rows="1"]. Prognosis is [select value="fair|good|poor"] considering the patient remains adherent to medication/therapy to address [textarea memo="target of treatment" rows="1"][checkbox value=" and whether they are able to engage constructively with social supports"].
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"]
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"]

PLAN: 
-Continue working with Psychiatrist
-The patient a demonstrated her journal taking during therapy and agreed to continue in journaling/reflective note-taking as discussed in the session, create a daily routine to encourage self-care, behavioral activation, and organization, consistently commit to daily routine/behavioral activation schedule|The patient will continue to think about joining a group therapy
-Follow Up in [text name="variable_1" default=""] week for continued psychotherapy
-The patient will contact emergency services for after hour care
-Discussed coping mechanisms and patient agreed to work on taking a step back and thinking before reacting