Psych office F/U July 3

[date name="date2" default="timestamp"] central time

[text name="name" memo="Patient name" size="20"]is a [select name="age" value="|18|19|20|21|22|23|24|25|26|27|28|29|30|31|32|33|34|35|36|37|38|39|40|41|42|43|44|45|46|47|48|49|50|51|52|53|54|55|56|57|58|59|60|61|62|63|64"] years-old, [select name="race" memo="race" value="|white|black|asian"],[select name="relationship" memo="Martial Status" value="|single|married|divorced|partnered"][select name="gender" memo="gender" value="|cis-gender female|cis-gender male|transgender female|transgender male|gender non-binary individual"]

History of Presenting Illness:
[var name="name"] that [select value="presents via telehealth|presents in this outpatient appointment "][select value="alone|with family |with significant other |with DHHS worker |with case manager |by police|"][text memo="names" size="20"][select value=" for evaluation and management of | due to reports of |"][checkbox name="concerns" value="depression|anxiety|cognitive impairment|impulsivity|mood lability|sleep disturbance"] [textarea memo="other" default="" rows="1"].[text memo="presenting problem" size="20"]. [select value="The patient reports |The family reports |The Guardian reports |The case manager reports |Electronic records indicate |Police report indicates |"][select value="a past history of|no history of mental health concerns until |no history of mental health concerns|"][textarea name="hx" memo="Mental health history" rows="2"]

[checkbox name="depression" memo="depression" value=""][checkbox name="anxiety" memo="anxiety" value=""][checkbox name="sleep" memo="sleep" value=""][checkbox name="mood" memo="mood" value=""][checkbox name="ptsd" memo="ptsd" value=""][checkbox name="adhd" memo="adhd" value=""][checkbox name="AdjustmentDisorder1" memo="Adjustment Disorder" value=""][checkbox name="autism" memo="autism" value=""][checkbox name="Panic1" memo="Panic" value=""]
[conditional field="depression" condition="(depression).is('')"]


[var name="name"]'s presents with symptoms [checkbox value="little interest or pleasure in doing things|hopelessness|helplessness|sleeping too much|difficulty getting to sleep|difficulty staying asleep|feeling tired or having little energy|poor appetite|overeating|feelings of inadequacy|irritability|poor concentration|psychomotor retardation|psychomotor agitation|suicidal ideation"]. [select value="Depressive symptoms are present most of the day, nearly every day|Depressive symptoms are mostly present |"][text size="20"][select value=", are exacerbated by |"][text size="20][select value=", are improved by |"][text size="20]. [select value="Depressive symptoms impact|"][select value=" social/work functioning by | "][textarea rows="1"].They rate their level of depression as [select value="1|2|3|4|5|6|7|8|9|10"]/10 , with 10 being the most severe..[textarea memo="Additional Depression information" rows="5"][/conditional]

[conditional field="anxiety" condition="(anxiety).is('')"]
[var name="name"]'s presents with symptoms [checkbox value="feeling nervous or on edge|worry|difficulty relaxing|feeling restless|difficulty getting to sleep|difficulty staying asleep|irritability|poor appetite|overeating"][text size="20]. [select value="Anxiety is present |"][select value="in the context of multiple different situations/events such as |primarily in social situations such as | "][textarea rows="1"]. [select value="Anxiety usually last for approximately |Anxiety is present most of the time on most days"][text size="20"][select value=", is brought on by |"][text size="20][select value=", is relieved by |"][text size="20]. Client rates anxiety [select value="1|2|3|4|5|6|7|8|9|10"]/10, with 10 being the most severe. [textarea memo="Additional Anxiety information" rows="5"][/conditional][conditional field="mood" condition="(mood).is('')"]

[select value=" Mood instability has been an issue since |"][text size="20"]. [select value="Disordered mood can present as |"][checkbox value="euphoria|excessive energy|excessive self-confidence|insomnia|irritability|agitation|racing thoughts|impulsive behavior|risk taking behavior|paranoia|delusions of grandeur|auditory hallucinations|visual hallucinations|depression|apathy|hopelessness|helplessness|suicidal thoughts|no motivation|hypersomnia"]. [select value="Mood lability is exacerbated by |There are no identified precipitating factors to mood lability|"][textarea rows="1"]. [textarea memo="additional information of mood lability" rows="4"][/conditional][conditional field="autism" condition="(autism).is('')"]

[select value="Per patient,|Per family,|Per record,|"][text size="20"][select value=" they have been | patient has been |"][select value="diagnosed|undiagnosed|"][text size="20"][select value=" autism spectrum disorder "][textarea memo="details of diagnosis/symptom timeframe" rows="4"]. [var name="name"]'s symptoms present as persistent difficulty, in multiple contexts, with social communication and interaction including: [checkbox value="abnormal or failed back and forth conversation|failure to initiate or respond to social interactions|reduced sharing of interests/emotions|limited emotional affect|limited/incongruent nonverbal communication|difficulty with developing/maintaining/understanding relationships|difficulty sharing imaginative play|limited or absent interest in peers"]. They have demonstrated restricted/repetitive patterns of behavior, interests, or activities including: [checkbox value="repetitive motor movements|repetitive speech|infexible adherence to routines|ritualized patterns of verbal or nonverbal behavior|significant difficulty with transitions|rigid thinking patterns|highly restricted and fixated interests|hyper-reactivity to sensory input|hyporeactivity to some sensory input"]. Presentation is [select value="without|with"] intellectual impairment, and [select value="without|with"] language impairment. [textarea rows="4"][/conditional][conditional field="adhd" condition="(adhd).is('')"]

[var name="name"] has a pattern of [checkbox name=addtype value="inattention and hyperactivity/impulsivity|inattention|hyperactivity/impulsivity"] that interferes with functioning. [/conditional][conditional field="addtype" condition="(addtype).is('inattention and hyperactivity/impulsivity')||(addtype).is('inattention')"] Inattention manifests as [checkbox memo="At least 6 for ADHD" value="poor attention to details or careless mistakes in work or activities|difficulty sustaining attention|not seeming to listen when spoken to directly|not following through on instructions or failing to finish tasks|having difficulty organizing tasks and activities|avoiding tasks that require sustained mental effort|frequently losing things necessary for tasks|often easily distracted by extraneous stimuli|forgetfulness in daily activities"].[/conditional] [conditional field="addtype" condition="(addtype).is('inattention and hyperactivity/impulsivity')||(addtype).is('hyperactivity/impulsivity')"] [var name="name"]'s hyperactivity/impulsivity presents as [checkbox memo="six or more for ADHD" value="frequent fidgeting or squirming|often leaving seat when remaining seated is expected|frequently restless|difficulty engaging in leisure activities quietly|often seeming to be on the go or difficult to keep up with|excessive talking|blurting out answers before a question has been completed|difficulty waiting for their turn|interrupting or intruding on others"].[/conditional][conditional field="adhd" condition="(adhd).is('')"] These symptoms have been present since [text memo="before 12yo" size="20"], and are recognized in multiple settings including [text memo="2 or more" size="20"]. [textarea rows="3"]

[/conditional][conditional field="sleep" condition="(sleep).is('')"]
Sleep is reported to be generally [select name="sleepq" value="poor |fair |good.|erratic |inconsistent |excessive|"][select value="with difficulty initiating sleep and staying asleep due to |with difficulty initiating sleep due to |with difficulty maintaining sleep due to |"][textarea rows="2"]. They estimate getting approximately [text size="4"] hours of [select value="broken |solid |"]sleep per night. [select value="Disturbed sleep has been an issue for |Disturbed sleep is a new issue within the last |"][textarea rows="1"]. [select value="There has been no workup for Sleep Apnea|There was a past workup for sleep apnea which indicated |"][textarea rows="1"]. [select value="Current attempts at improving sleep include |The patient is currently attempting no interventions to improve sleep|Current quality of sleep is dependent on |"][textarea rows="2"]. [select value="Past unsuccessful attempts at improving sleep include |There have been no past attempts at improving sleep|"][textarea rows="2"].[/conditional]

[conditional field="ptsd" condition="(ptsd).is('')"] PTSD symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|nightmares|flashbacks|intrusive memories/thoughts|avoidance|negative affect|loss of interest|isolation|difficulty experiencing positive emotions|irritability|easily annoyed|risky/self destructive behaviors|hypervigilance|heightened startle reaction|difficulty concentrating|difficulty falling asleep|difficulty staying asleep"].[textarea memo="Additional information" rows="1"][/conditional] 


[conditional field="AdjustmentDisorder1" condition="(AdjustmentDisorder1).is('')"] Adjustment disorder symptoms are [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="marked distress that is disproportionate to the severity/intensity of stressor|significant impairment in social, occupational, and other areas of functioning|depressed/low mood|anhedonia|tearfulness|feelings of hopelessness|nervousness|excessive worrying|difficulty concentrating|feeling overwhelmed"].[/conditional]


[conditional field="Panic1" condition="(Panic1).is('')"] Panic symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|palpitations/racing heart|sweating|shortness of breath|chest pain/tightness|nausea/stomach cramps|numbness/tingling|fear of losing control|closed in feeling|feeling overwhelmed|heat sensations|trembling/shaking"].[textarea memo="Additional information" rows="1"][/conditional]


[checkbox name="Symptomsmanagement" memo="Symptoms/Management" value=""][checkbox name="ADHD" memo="ADHD" value=""][checkbox name="GenderSexuality" memo="Gender/Sexuality" value=""][checkbox name="Other" memo="Other" value=""][checkbox name="Attachmentissues" memo="Attachment issues" value=""][checkbox name="Behavioralhealthissues" memo="Behavioral health issues" value=""][checkbox name="Substanceuse" memo="Substance use" value=""][checkbox name="Trauma" memo="Trauma" value=""][checkbox name="Relationships" memo="Relationships" value=""][checkbox name="Interpersonal" memo="Interpersonal" value=""][checkbox name="Adjustment" memo="Adjustment" value=""][checkbox name="Griefloss" memo="Grief/loss" value=""][checkbox name="Stressors" memo="Stressors" value=""][conditional field="Symptomsmanagement" condition="(Symptomsmanagement).is('')"][checkbox value= "Current symptoms/functioning|Symptom management|Management of depressive symptoms|Management of anxiety symptoms|Emotional dysregulation|Distress intolerance|Anger issues|Mood management|Impacts of symptoms"][/conditional][conditional field="ADHD" condition="(ADHD).is('')"][checkbox value= "ADHD symptoms/diagnosis|ADHD treatment/medications|Self-esteem|Management of executive dysfunction"][/conditional][conditional field="GenderSexuality" condition="(GenderSexuality).is('')"][checkbox value= "Gender identity|Sexual orientation|Coming out process|Reactions from family/friends/others"][/conditional][conditional field="Other" condition="(Other).is('')"][checkbox value= "Homework/assignment follow up|Goals/treatment plan review|Client history/background"][/conditional][conditional field="Attachmentissues" condition="(Attachmentissues).is('')"][checkbox value= "Adult attachment style issues|Attachment anxiety and avoidance|Adult attachment anxiety|Fear of developing intimate relationships|Fear of interpersonal rejection and/or abandonment|Adult attachment avoidance|Fear of intimacy|Excessive need for self-reliance|Distrust of others"][/conditional][conditional field="Relationships" condition="(Relationships).is('')"][checkbox value= "Relationship dissatisfaction|Conflict/argument with partner|Intimacy concerns|Infidelity/affair concerns|Child custody conflict|Codependency issues|Divorce issues|Trust concerns|Communication problems with partner|Breakup/acute relationship concerns|Abuse/IPV|Relationship trauma|Previous relationship issues"][/conditional][conditional field="Adjustment" condition="(Adjustment).is('')"][checkbox value= "Adjustment to stressor(s)|Adjustment to workplace changes|Adjustment to job loss/change|Adjustment to relationship changes|Adjustment to family life changes|Adjustment to a developmental event"][/conditional][conditional field="Griefloss" condition="(Griefloss).is('')"][checkbox value= "Death of a family member|Death of a friend|Grief reactions|Processing past regrets|Processing grief|Processing a death/loss"][/conditional][conditional field="Interpersonal" condition="(Interpersonal).is('')"][checkbox value= "Interpersonal conflict(s)|Conflict with friends|Conflict with family of origin|Conflict within nuclear family|Conflict with partner/spouse|Conflict with coworker(s)|Communication issues|Poor boundary setting/People pleasing|Difficulty saying no to others|Passive behaviors|Aggressive behaviors"][/conditional][conditional field="Behavioralhealthissues" condition="(Behavioralhealthissues).is('')"][checkbox value= "Self-care activities|Sleep difficulty/concerns|Nutrition/eating habits|Physical activity/exercise|Daily scheduling|Energy levels"][/conditional][conditional field="Substanceuse" condition="(Substanceuse).is('')"][checkbox value= "Substance use concerns|Alcohol use concerns|Cannabis use concerns|Tobacco use concerns|Relapse prevention"][/conditional][conditional field="Trauma" condition="(Trauma).is('')"][checkbox value= "Family of origin dynamics|Past trauma event|Recent trauma event|Sexual trauma event|Childhood trauma|Past childhood abuse/neglect|Past distressing memory"][/conditional][conditional field="Stressors" condition="(Stressors).is('')"][checkbox value= "Life stressors|Stressor/coping mechanism(s)|Family dysfunction|Work problems|School problems|Bullying|Work-related stress|Negative work environment|Difficulty with work/life balance|Financial issues|Legal issues|Housing issues|Relationship issues|Parenting stress/issues"][/conditional]

Social/friendships: [select name="functioning2" value="No|Mild|Moderate|Severe"] disruption to the client’s ability to engage and/or derive satisfaction from social connections. 
Daily tasks: [select name="functioning3" value="No|Mild|Moderate|Severe"] disruption to the client’s ability to perform daily necessary tasks for life. 
Family: [select name="functioning4" value="No|Mild|Moderate|Severe"]  disruption to the client’s satisfaction and stability in family life and connection.
Work/Academic: [select name="functioning5" value="No|Mild|Moderate|Severe"] disruption to the client’s satisfaction or productivity in the client’s function at work/school.
Economic: [select name="functioning6" value="No|Mild|Moderate|Severe"] disruption to the client’s financial stability. 
Romantic relationships: [select name="functioning7" value="No|Mild|Moderate|Severe"] disruption to the client’s satisfaction from or ability to engage in romantic relationships.

TREATMENT AND PRESCRIPTIONS
[select name="prescription1" text memo="Rx #1" value="Azstarys 39.2 mg as needed per day|Azstarys 52.3 mg as needed per day|Azstarys 26.1 mg as needed per day|Adderall XR 5 mg as needed per day| |Adderall XR 10 mg as needed|Adderall XR 15 mg as needed per day||Adderall XR 20 mg as needed per day| |Adderall XR 25 mg as needed| |Adderall XR 30 mg as needed per day| Mydaysis 10mg as needed per day|Mydaysis 25 mg as needed per day|Mydayis 37.5 mg as needed per day|Mydayis 50 mg as needed per day|Wellbutrin SR 150mg daily|Wellbutrin XR 150mg daily| Wellbutrin XR 300 mg daily|Vyvanse 20 mg as needed per day|Concerta |methylphenidate|Strattera 40mg daily|Qelbree 200mg daily|Intuvia 1mg daily|Vraylar 1.5 mg daily"]
[select name="prescription2" text memo="Rx #2" value="|Azstarys 39.2 mg as needed per day|Azstarys 52.3 mg as needed per day|Azstarys 26.1 mg as needed per day|Adderall XR 5 mg as needed per day| |Adderall XR 10 mg as needed|Adderall XR 15 mg as needed per day||Adderall XR 20 mg as needed per day| |Adderall XR 25 mg as needed| |Adderall XR 30 mg as needed per day| Mydaysis 10mg as needed per day|Mydaysis 25 mg as needed per day|Mydayis 37.5 mg as needed per day|Mydayis 50 mg as needed per day|Wellbutrin SR 150mg daily|Wellbutrin XR 150mg daily| Wellbutrin XR 300 mg daily|Vyvanse 20 mg as needed per day|Concerta |methylphenidate|Strattera 40mg daily|Qelbree 200mg daily|Intuvia 1mg daily|Vraylar 1.5 mg daily"]
[select name="prescription3" text memo="Rx #3" value="|Azstarys 39.2 mg as needed per day|Astarys 52.3 mg as needed per day|Astarys 26.1 mg as needed per day|Adderall XR 5 mg as needed per day| |Adderall XR 10 mg as needed|Adderall XR 15 mg as needed per day||Adderall XR 20 mg as needed per day| |Adderall XR 25 mg as needed| |Adderall XR 30 mg as needed per day| Mydaysis 10mg as needed per day|Mydaysis 25 mg as needed per day|Mydayis 37.5 mg as needed per day|Mydayis 50 mg as needed per day|Wellbutrin SR 150mg daily|Wellbutrin XR 150mg daily| Wellbutrin XR 300 mg daily|Vyvanse 20 mg as needed per day|Concerta |methylphenidate|Strattera 40mg daily|Qelbree 200mg daily|Intuvia 1mg daily|Vraylar 1.5 mg daily"]
[text name   memo="Rx other" ="variable_1" default=""]

[var name="name"] is a [var name="age"] year old [var name="relationship"] [var name="race"] [var name="gender"] with past psychiatric history of [var name="hx"], presenting with concerns for [var name="concerns"]. Based on [var name="name"]’s interview, review of symptoms, screening measures, and this provider’s thorough assessment, the patient has met the DSM-V diagnostic criteria for [checkbox name="dx" value="Major depressive disorder|recurrent|single episode|mild|moderate|severe|Bipolar II|Depression|Manic|hypomania|Mixed|without psychosis |with psychosis|Generalized anxiety disorder|Insomnia|PTSD |acute|chronic|ADHD |inattentive type|hyperactive type|mixed|Adjustment Disorder|with depressed mood|with anxiety|with depressed mood and anxiety"][textarea rows="1"].


[var name="name"] reports the symptoms are causing maladaptive functioning and impairment in their personal, occupational, and social settings. [var name="name"] has been unable to alleviate these symptoms on their own through non-pharmacological interventions and are in need of medication management which will require continued treatment.[var name="name"] currently denies suicidal or homicidal ideation.

Medication choices were discussed and the provider and patient agreed that [var name="prescription1"], [var name="prescription2"], [var name="prescription3"] will be beneficial to manage [var name="name"]'s symptoms.[var name="name"] verbalized their consent and willingness to participate in the following proposed treatment plan.

We reviewed therapeutic duration of medication, dosing strategies, side effects, and assessing improvements in symptoms.

[var name="name"] would benefit from [checkbox value="initiation of psychopharmaceutical intervention|continued psychopharmaceutical intervention|adjustments to current psychopharmaceutical intervention"] [textarea rows=""]

Pharmacological Interventions:
Start: [var name="prescription1"][var name="prescription2"] [var name="prescription3"] 
[select value="|N/A |Discontinue:|Continue:"] 

Non-Pharmacological Interventions:
[var name="name"] would benefit from [checkbox value="initiation of psychotherapy|continuation of current psychotherapy|engaging in grief therapy|engaging in CBT|engaging in family therapy|enhanced psychosocial supports|increasing personal time and self-care"]
1. Eating a balanced diet
2. Exercising at least three times a week
3. Psychotherapy
4. Increasing personal time and self-care
[textarea rows=""]

*Please be aware that this note was generated using voice dictation. Although we have made every effort to ensure the accuracy and completeness of the note, errors and omissions may occur.
central time

Patient nameis a years-old, race,Martial Statusgender

History of Presenting Illness:
name that names
other.presenting problem.
Mental health history

depression anxiety sleep mood ptsd adhd Adjustment Disorder autism Panic













Symptoms/Management ADHD Gender/Sexuality Other Attachment issues Behavioral health issues Substance use Trauma Relationships Interpersonal Adjustment Grief/loss Stressors

Social/friendships: disruption to the client’s ability to engage and/or derive satisfaction from social connections.
Daily tasks: disruption to the client’s ability to perform daily necessary tasks for life.
Family: disruption to the client’s satisfaction and stability in family life and connection.
Work/Academic: disruption to the client’s satisfaction or productivity in the client’s function at work/school.
Economic: disruption to the client’s financial stability.
Romantic relationships: disruption to the client’s satisfaction from or ability to engage in romantic relationships.

TREATMENT AND PRESCRIPTIONS
Rx #1
Rx #2
Rx #3
Rx other

name is a age year old relationship race gender with past psychiatric history of hx, presenting with concerns for concerns. Based on name’s interview, review of symptoms, screening measures, and this provider’s thorough assessment, the patient has met the DSM-V diagnostic criteria for
.


name reports the symptoms are causing maladaptive functioning and impairment in their personal, occupational, and social settings. name has been unable to alleviate these symptoms on their own through non-pharmacological interventions and are in need of medication management which will require continued treatment.name currently denies suicidal or homicidal ideation.

Medication choices were discussed and the provider and patient agreed that prescription1, prescription2, prescription3 will be beneficial to manage name's symptoms.name verbalized their consent and willingness to participate in the following proposed treatment plan.

We reviewed therapeutic duration of medication, dosing strategies, side effects, and assessing improvements in symptoms.

name would benefit from


Pharmacological Interventions:
Start: prescription1prescription2 prescription3


Non-Pharmacological Interventions:
name would benefit from
1. Eating a balanced diet
2. Exercising at least three times a week
3. Psychotherapy
4. Increasing personal time and self-care


*Please be aware that this note was generated using voice dictation. Although we have made every effort to ensure the accuracy and completeness of the note, errors and omissions may occur.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.73, 191 form elements, 290 boilerplate words, 17 text boxes, 21 text areas, 1 dates, 50 checkboxes, 50 drop downs, 27 variables, 25 conditionals, 371 total clicks
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