Psych f/u

Chart reviewed and care discussed with interdisciplinary team during morning report. No acute events overnight. Pt observed in [select name="variable_room" value="milleu|his room"],    calm and cooperative. Today, patient reports he is “[comment memo="MOOD"] [text name="variable_mood" default=""]". Veteran reports[comment memo="SYMPTOMS"][select name="variable_sx" value="depression|anxiety|depression and anxiety"], rated [comment memo="RATED"][text name="variable_rate" default="/10"] in intensity, which is [comment memo="MOOD IMPROVEMENT"][select name="variable_improvement1" value="improved|worse|the same"] compared to previous days. Patient    endorses    [comment memo="SYMPTOM    IMPROVEMENT"][text name="variable_symptom2" default=""].    Patient reports [comment memo="SLEEP"][select name="variable_sleepquality" value="good sleep, feeling rested in the morning|interrupted sleep, with frequent awakenings|difficulty falling asleep|difficulty staying asleep|difficulty falling and staying asleep"] with [comment memo="NIGHTMARES"][select name="variable_nightmares" value="no nightmares|reported nightmares"]. Appetite has been [comment memo="APPETITE"][select name="variable_appetite" value="good, unchanged from previous days|improving slightly compared to previous days|poor, with little interest in food"].    Patient is    [comment memo="COMPLIANCE"][select name="variable_compliance" value="compliant|non-compliant"]  with    currently    prescribed    medications    and    [comment memo="SIDE EFFECTS"][select name="variable_sideeffects" value="denies side effects|reports side effects of _____"]. Veteran endorses [comment memo="MED IMPROVEMENT"][select name="variable_improvement2" value="good therapeutic benefit|lack of therapeutic benefit"] from current medication regimen. Patient [comment memo="SI"][select name="variable_SI" value="denies SI, HI, |reported SI _____, denied HI,|reported HI_____, denied SI,"][select name="variable_hallu" value="A/V    hallucinations, delusions or paranoia|; reported hallucinations _____|;reported delusions ____|displayed signs of paranoia _____"]. Per chart review, patient [comment memo="GROUPS"][select name="variable_groups" value="attended ________ group yesterday with good engagement|was not able to attend groups yesterday due to ____|did not participate in groups or activities provided yesterday"].
 
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Psychiatric ROS:[comment memo="ROS" memo_size="large"]
 
- Depression: [checklist name="variable_rosdep" value="None endorsed|depressed mood|feelings    of hopelessness|feelings    of helplessness|anhedonia|changes in    appetite|difficulty sleeping|psychomotor    retardation"]
- Anxiety: [checklist name="variable_rosanx" value="None    endorsed|anxious mood|restlessness|increased    worry|muscle tensions|rapid heartbeat|difficulty    concentrating"]
- Mania: [checklist name="variable_rosmanic" value="None    endorsed|high levels    of    energy|elevated mood|pressured    speech|overproductive speech|increased goal    directed activities|flight of    ideas|decreased need    for sleep|psychomotor agitation"]
- PTSD:[checklist name="variable_rosptsd" value="None endorsed|intrusive    thoughts/memories|nightmares|sleep    disturbance|flashbacks|avoidance|dissociative    amnesia|persistent negative emotional    state|low interest in participating in    activities|inability to experience    positive    emotions|hypervigilance|exaggerated    startle|aggresive    behavior"]
- Psychosis: [checklist name="variable_rospsycho" value="None endorsed|persecutory    delusions|grandiose delusions|somatic    delusions|referential    delusions|auditory    hallucinations|visual hallucinations|disorganized speech|word salad|neologisms|catatonia|agitation|echolalia|echopraxia|stereotyped movements|flat    affect|anhedonia|alogia"]
- Impulsiveness: [checklist name="variable_rosimpulsive" value="None    endorsed|angry outbursts|daredevil behavior|destruction of property|hyperactivity/impulsivity|substance use related behaviors"]

Mental Status Exam (MSE)[comment memo="MentalStatus"]
 
-    Orientation: oriented to [select name="variable_orientation" value="person, time, place|person only"].
-    Appearance: [select name="variable_appearance" value="dressed appropriately for weather, adequately    groomed,well nourished|disheveled"].
-    Behavior: [select name="variable_behavior" value="calm,cooperative|agitated, in psychological distress|withdrawn, with poor eye contact|hostile|uncooperative"].
-    Mood: [select name="variable_mood" value="euthymic|depressed|anxious"].
-    Affect intensity: [select name="variable_affect" value="appropriate|restricted|blunted|flat"],    [select name="variable_congruent" value="congruent with mood|incongruent with    mood"].
-    Thought process: [select name="variable_process" value="logical, coherent and organized|tangential|circumstantial"]
-    Thought content: [select name="variable_content" value="no signs of perceptual disturbances|paranoia|delusional thoughts|broadcasting|thought insertion|fixation and rumination"]
-    Attention: [select name="variable_attention" value="no difficulty with attention or concentration|had some attentional and concentration problems during the exam"].
-    Insight: [select name="variable_insight" value="fair|poor"].
-    Judgment: [select name="variable_judgement" value="fair|poor"].
-    Cognition/Memory: [select name="variable_cognition" value="grossly intact|below average"].
 
ASSESSMENT AND RESPONSE TO TREATMENT:
Patient was evaluated today and reported [var name="variable_sx"] [var    name="variable_symptom2"],    [var name="variable_improvement1"]from    yesterday. Veteran    is    [var    name="variable_compliance"] and    [var name="variable_sideeffects"] with    current    medication    regimen.    Patient’s affect was [var name="variable_affect"]; thought process was [var name="variable_process"]; thought content showed [var name="variable_content"]. He    [var name="variable_SI"][var name="variable_hallu"]. 

Based on today's evaluation, the patient’s symptomatology is [var name="variable_improvement1"] and current medications have shown [var name="variable_improvement2"] without major side effects. Plan is to [comment memo="MedPlan"][select name="variable_plan1" value="continue with the same dose of current medications, as they has shown significant therapeutic benefit, effectively improving the patient’s symptoms|start trial of ______  to address ______ . Will continue the same dose of other medications, as they has shown significant therapeutic benefit, effectively improving the patient’s symptoms|increase ______, as patient continues to experience residual symptoms despite the current dose|discontinue ______, as it has has proven ineffective in managing the patient's symptoms, necessitating the exploration of alternative therapeutic options|decrease ______, as patient is experiencing dose-related side effects and lack of therapeutic benefit "]. Will follow-up tomorrow to reassess symptomatology and treatment response.    In    terms    of    discharge    planning,    [text name="variable_discharge" default=""]He    is    not    an    imminent    risk    to    self    or    others    at    this    time.