PSYCH SOAP FDU Spring 2019
Subjective: [textarea cols=80 rows=1 default="one or more symptoms in patient's words, duration..."] [textarea cols=80 rows=2 default="MOOD : This is what the pt. tells you. it's subjective."] [textarea cols=80 rows=3 default="PECEPTION (subjective): quanitty, quality and rate| Clear, delayed, excessive, pressured, slurred, fast"] Objective: Physical Examination [textarea cols=80 rows=2 default="VITALS: Height/Weight/Temperature/Heart Rate/Blood Pressure/Pain Level"] [textarea cols=80 rows=2 default="GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress."] [textarea cols=80 rows=3 default="Pain:Scale of 0-10"] [textarea cols=80 rows=1 default="Memory:Immediate, recent and remote|intact or impaired."] [textarea cols=80 rows=1 default="Cognition: Intelligence level (ask simple math questions)|interste: average/below average Concrete thinking (what does don't put all your eggs in one basket mean):"] [textarea cols=80 rows=1 default="Attitude: interactions with interviewer| cooperateive guarded, hostile"] [textarea cols=80 rows=2 default="GENERAL APPEARANCE: Dress, grooming, apparent age, weight (under/over) | pt disheveled bizzare, older than stated age OR Well developed, well nourished, alert and cooperative, and appears to be in no acute distress."] [textarea cols=80 rows=2 default="MOTOR ACTIVITY: body lanugage|hypo/hypoactive, restless, psychomotor tetardation or agitation."] [textarea cols=80 rows=1 default="AFFECT: Facial Expression: appropriate, ablile, flat, blunt, constricted."] [textarea cols=80 rows=3 default="SPEECH: quanitty, quality and rate| Clear, delayed, excessive, pressured, slurred, fast"] [textarea cols=80 rows=3 default="THOUGHT PROCESS: Form and content: Logical vs illoggical, loose association, flight of ideas, thought bblocking, delusions, goal directied"] [textarea cols=80 rows=3 default=" SUICIDAL/HOMICIDAL IDEAS: Presence of as described by patient through direct questioning Denied, present with plan, ability to contract for safety"] [textarea cols=80 rows=3 default=" INSIGHT/JUDGEMENT: Ability to assess and evaluate situations and understand consequences of own acts Impaired (“the police brought me in, but I don’t know why”). Intact"] [textarea cols=80 rows=3 default="MED COMPLAINT: Did your patient take their medications today? Require prn? Medication adherent or Mediation noncompliant"] [textarea cols=80 rows=3 default="SPEECH: quanitty, quality and rate| Clear, delayed, excessive, pressured, slurred, fast"] [textarea cols=80 rows=3 default="PARTICIPATING IN MILIEU: Attending groups? Social with peers? Isolative? i.e. attended recreation group with active participation.Refused group despite /encouragement & teaching."] [textarea cols=80 rows=3 default= Teaching Needs Medication, safety, hygiene, smoke cessation, etc" [textarea cols=80 rows=3 default= REDINESS TO LEARN"] Medications: [textarea cols=80 rows=5 default="medication name/dose/indication/duration"] Assessment: [textarea cols=80 rows=1 default="Five word summary of your observations of the patient"] Plan: LONG (DISCHARGE) AND SHORT (TODAY) TERM GOALS [textarea cols=80 rows=2 default="#1 Problem"] [textarea cols=80 rows=2 default="#2 Problem"] [textarea cols=80 rows=2 default="#3 Problem"] [textarea cols=80 rows=2 default="#4+ Problem"] Intervention/Evaluation: [textarea cols=80 rows=5 default="must be realistic, measurable, patient specifica and time bound"] PREFERRED LEARNING STYLE: [textarea cols=80 rows=5 default="Verbal, written, group"] VISITORS: [textarea cols=80 rows=5 default= "How did the interaction go? i.e. husband visited without incident"] DISCHARGE PLANNING [textarea cols=80 rows=5 default="m Discharge Planning (housing; program referrals; scheduled appointments; focus of teaching; etc) "]
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0, 30 form elements, 22 boilerplate words, 30 text areas, 30 total clicks
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