PsychEval: ID/CC/HPI
Patient Data First Name: [text name="fname" default=""] Last Name: [text name="lname" default=""] Age: [text name="age" default=""] Race: [text name="race" default=""] Sex: [text name="sex" default=""] Current City: [text name="currentcity" default=""] Allergies: [text name="algy" default=""] Primary Care Provider: [text name="currentpcp" default=""] Caregiver First Name: [text name="adult_fname" default=""] Last Name: [text name="adult_lname" default=""] Relationship to Patient: [text name="adult_id" default=""] Referring Source First Name: [text name="referring_fname" default=""] Last Name: [text name="referring_lname" default=""] Credentialing: [select name="referring_credential" value="LPC|LSW|LCSW|LMSW||CMHP|choice C"] Chief Complaint: [textarea name="cc" default=""] General Medical History Patient has an allergy to [PCN]. Patient is currently prescribed [medication]. Patient’s immunizations are up to date. There are no reports of asthma, diabetes, hypothyroidism, TB, seasonal allergies or seizure. There were no reports of any surgeries or hospitalizations. Identifying Data/Chief Complaint: [var name="fname"] [var name="lname"] is a [var name="age"] year old [var name="race"] [var name="sex"] presenting for initial assessment and pharmacologic management of [var name="dx"]. Patient's [var name="adult_id"], [var name="adult_fname"] [var name="adult_lname"], brought [var name="fname"] for evaluation and lives in [var name="city"], [var name="state"]. Patient referred by [var name="refsource"] with a chief complaint of "[var name="cc"]". History of Present Illness: [var name="fname"] [var name="lname"] is a [var name="age"] year old [var name="race"] [var name="sex"] presenting for initial assessment and pharmacologic management of [var name="dx"]. Patient's [var name="adult_id"], [var name="adult_fname"] [var name="adult_lname"], brought [var name="fname"] for evaluation and lives in [var name="city"], [var name="state"]. Patient was referred as mentioned with the above chief complaint. Symptoms first noticed by [var name="fname"]'s [var name="adult_id"] a [race, sex, maritial statues] here for initial assessment and pharmacologic management of ADHD, [diagnosis]. He was brought by his [parent/guardian name] for evaluation and lives in [Monett Missouri]. Consent to medical evaluation via telemedicine verified. Patient was referred by [hospital/case manager/friend] with a chief complaint of "[in own words]". History of Present Illness: [Name ] is a [age] year old [sex, maritial status] here for initial assessment and pharmacologic management of ADHD, [diagnosis]. He was brought by his [parent/guardian] for evaluation and lives in [Monett Missouri]. Patient was referred as mentioned with the above chief complaint. Parents first notice symptoms when patient was [age first symptoms] and these consisted of [initial symptoms]
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0.07, 43 form elements, 260 boilerplate words, 13 text boxes, 1 text areas, 1 drop downs, 28 variables, 15 total clicks
More SOAPnotes by this Author:
Send Feedback for this SOAPnote
You must be logged in to post a comment.