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)
"]