Psych Jail Note

[date name="Date" format="mm-dd-yy"]
[select name="VisitType" value="Psychiatric Intake|Psychiatric Follow Up"]
Provider: Josh Raufman PMHNP

[text name="ChiefComplaint" memo="Chief Complaint"]

[textarea name="HPI" memo="HPI"]

[textarea name="MedicalHx" memo="Pertinent PMH:"]

Legal History: [text name="legal" memo="Legal History"]
Current Charges: [text name="legal" memo="Legal History"]
Chart Review:
Chart Review: [textarea name="social" memo="Social Hx"]

Psychiatric History:
[checklist name="PsychiatricHx" value="Depression|Anxiety|Mood Disorder|Schizophrenia|Schizoaffective DO|ADHD|PTSD|OCD"]
[text name="Other" memo="Other:"]
Past Psychiatric Hospitalizations:
[radio name="PastPsychHospitalization" value="Denies|Yes|Unable to Assess"]
[text name="Details" memo="Details:"]

Social History: [textarea name="social" memo="Social Hx"]

Past Psychiatric Meds
[checkbox name="PriorPsychMeds" value="SRI's|Mood stabilizers|Benzodiazepenes|Psychostimulants|Alpha modulators|D2 antagonists|Other"]
[textarea name="priorpsychmeds" memo="Past Psych Meds:"]
Substance Use Hx:
[checklist name="substances" value="Alcohol|Cannabis|Methamphetamine|Cocaine/Crack|Opioids|Heroin|Fentanyl|Psychedelics "] [text name="other"]
Trauma History:
[checkbox name="Trauma" value="Physical abuse|Emotional abuse|Neglect|Sexual abuse|Sexual assault|Combat|violence|Other"] [text name="other"]
Incarceration Hx:
[radio name="IncarcerationHx" value="First incarceration|1-3 prior incarcerations|>3 prior incarcerations"]
[text name="other" memo="Details:"]

Review Of Systems:
Depression[radio name="depressiontype" value="Pure Depression|Atypical depression|Neurotic Depression|Melancholic depression|Mixed depression|None Identified"] [text name="other"]
Anxiety: [checkbox name="anxiety" value="||Psychic anxiety symptoms|Somatic anxiety symptoms|Agitated Anxiety|Restlessness|Racing Thoughts|Flight of Ideas|Panic Attacks|Rumination|Denies"] [text name="other"]
Mood Lability: [checkbox name="Lability" value="Denies|Yearly|Monthly|Weekly|Daily|Hourly|Variable|Abrupt Shifts|Gradual Shifts|Unable to assess"][text name="other"]
Irritability: [radio name="Irritability" value="Denies|Endorses|unable to assess"] [text name="other"]
Sleep: [checkbox name="Sleep" value="No concerns|Delayed Sleep Onset|Frequent awakening|Nightmares|Restless Sleep|Unrestful sleep|hypersomnia"][text name="other"]
Energy: [checkbox name="energy" value="No change from baseline|Decreased from baseline|increased from baseline|variable|unable to assess"] [text name="other"]
Psychosis: [checkbox name="psychosis" value="Denies|Auditory Hallucinations|Visual Hallucinations|Other hallucinations|Delusional thoughts|paranoid thoughts|disorganized thoughts|Unable to assess"] [text name="other"]
[text name="other" memo="Details:"]
PTSD: [checkbox name="ptsd" value="Denies|Increased startle response|Flashbacks|Nightmares|Hypervigilance|Derealization|Dissociation"]
Other: [text name="other" memo="other"]
Patient's review of systems reveals no significant findings or concerns in all other areas except those listed as positive above.

Mental Status Exam:
[checkbox name="Distress" value="No apparent Distress|Distressed|Agitated"]
[checkbox name="develop" value="well developed|undernourished"]
[radio name="weight" value="Normal Body habitus|Overweight |Obese|Thin|Cachectic"]
[radio name="age" value="Appears stated age|appears younger than stated age|appears older than stated age"]
[checkbox name="hygiene" value="Good hygiene|Appropriately Dressed|Inappropriately Dressed|Disheveled|malodorous"]
Attitude: [checkbox name="attitude" value="Cooperative|Engaged|Hostile|Guarded|Evasive|Apathetic|Disorganized behavior|Irritable"] [text name="details"]
Psychomotor: [checkbox name="psychomotor" value="Unremarkable|agitated|restless|retarded or slowed|tremor|tics|rigidity|dystonia|dyskinesias|pacing|stereotyped behaviors|gesticulations|posturing|akathisia"]
Eye Contact: [checklist name="eye" value="Appropriate|downcast|staring|evasive|furtive|intense or glaring"]
Attitude Toward Provider: [checkbox name="attitude" value="Pleasant|Cooperative|Approval-seeking|Dramatic|Passive|Bored|Silly|Resistant|Critical|Irritable|Hostile|Sarcastic|Argumentative|Provocative|Demanding|Threatening|Suspicious|Guarded|Defensive|Manipulative"]
Speech: [checkbox name="speech" value="Fluent|Incoherent|Mute"]
[checkbox name="Tone" value="Normal Tone|High Tone|Low tone|monotonous Tone"]
[radio name="rate" value="Normal Rate|Increased rate|Decreased rate"]
[checkbox name="Talk" value="Talkative|Reticent|flattened|amplified|exaggerated|staccato|pressured|hesitant|slurred|mumbling|muttering|stuttering|aphasia"]
Mood: [checkbox name="mood" value="Euthymic|Dysphoric|Manic|anxious|despondent|agitated"]
Affect: [checkbox name="Affect" value="Congruent|Incongruent|Labile|Stable|Flat|blunted|restricted|reactive|expansive|euphoric|apathetic"]
Thought Content: [checkbox name="Thoughtcont" value="Unremarkable|Suicidal Ideation|Homicidal Ideation|Delusional|Paranoid|persecutory|grandiose|obsessional"] [text name="details"]
Thought Process: [checkbox name="thoughtcontent" value="Congruent to mood and circumstances|Incongruent|Ideas of reference|Suspicions|Ideas of influence|Illusions|Monomania|Delusions"]
Abstraction: [checkbox name="realitytesting" value="Normal|Concrete|Functional|Popular|Abstract|Overly abstract"]
Thought Process: [checkbox name="ThoughtProc" value="Linear|coherent|goal oriented|ruminating|perseverative|rambling|impoverished|Loose associations|circumstantial|tangential|magical thinking|Responding to internal stimuli|ideas of reference|Racing Thoughts|Flight of ideas|disorganized|word salad|Incoherent|Echolalia|Broadcasting"][text name="details"]
Sensorium: [checkbox name="sensorium" value="Awake and alert|Sedated or drowsy|Disorientated|Fluctuating sensorium|obtunded|Hallucinations"]
Memory: [checkbox name="Memory" value="Memory grossly intact|Abnormal remote memory|abnormal remote memory|abnormal recall|abnormal word finding"]
Fund of information: [checkbox name="Fund" value="Good|average|fair|poor"]
Attention:[checkbox name="attention" value="Alert|Inattentive|Unfocused|Wanders|Unaware|Vigilant"]
Concentration: [checkbox name="concentration" value="Normal|Distractible|Drowsy/Tired|Lethargic|Confused|Bewildered|anxiety interferes|Focuses on irrelevancies|Preoccupied"]


Intelligence: [radio name="intelligence" value="average|below average|above average|unable to assess"]
Impulse Control: [radio name="impulse" value="Good|Fair|Questionable|Poor|unable to assess"]
Insight: [radio name="insight" value="Good|Fair|Questionable|poor|unable to assess"]
Decision Making: [checkbox name="decisionmaking" value="Normal|Only simple|Impulsive|Vacillates|Confused|Paralyzed"]
Judgement: [radio name="judgement" value="Good|Fair|Questionable|Poor|unable to assess"]
Abnormal Movements: [checkbox name="EPS" value="No EPS noted|Dystonia|Akathisia|Parkinsonism|Other"]
[text name="other" memo="Details:"]
Risk of Harm to Self or Others: [checkbox name="risk" value="Denies|Passive|Plans|Means|Threat|Preoccupation|Gesture|Attempt|Other:"]

ASSESSMENT:[textarea name="ASSESSMENT" memo="ASSESSMENT"]

PLAN: [textarea name="PLAN" memo="PLAN"]

FOLLOW UP:[radio name="Followup" value="1 Week|2 Weeks |4 Weeks|6 Weeks|8 Weeks|As needed"] [text name="FOLLOWUP" memo="Follow Up"]


Provider: Josh Raufman PMHNP

Chief Complaint

HPI

Pertinent PMH:

Legal History: Legal History
Current Charges: Legal History
Chart Review:
Chart Review:
Social Hx

Psychiatric History:

Other:
Past Psychiatric Hospitalizations:

Details:

Social History:
Social Hx

Past Psychiatric Meds

Past Psych Meds:
Substance Use Hx:

Trauma History:

Incarceration Hx:

Details:

Review Of Systems:
Depression
Anxiety:
Mood Lability:
Irritability:
Sleep:
Energy:
Psychosis:
Details:
PTSD:
Other: other
Patient's review of systems reveals no significant findings or concerns in all other areas except those listed as positive above.

Mental Status Exam:





Attitude:
Psychomotor:
Eye Contact:
Attitude Toward Provider:
Speech:



Mood:
Affect:
Thought Content:
Thought Process:
Abstraction:
Thought Process:
Sensorium:
Memory:
Fund of information:
Attention:
Concentration:


Intelligence:
Impulse Control:
Insight:
Decision Making:
Judgement:
Abnormal Movements:
Details:
Risk of Harm to Self or Others:

ASSESSMENT:
ASSESSMENT

PLAN:
PLAN

FOLLOW UP: Follow Up

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.62, 77 form elements, 109 boilerplate words, 22 text boxes, 7 text areas, 1 dates, 31 checkboxes, 3 check lists, 12 radio buttons, 1 drop downs, 309 total clicks
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