RA 4

PSYCH: [comment memo="*" memo_size="small" memo_color="blue"][conditional field="PSYexamdetailed" condition="(PSYexamdetailed).isNot('')"][text default="denies any changes in mood, depression, anxiety, sleep disturbance or problems with substance or alcohol use." size="80"][/conditional][checkbox name="PSYexamdetailed" memo="more detail" memo_size="small" memo_color="yellow" value=""][conditional field="PSYexamdetailed" condition="(PSYexamdetailed).is('')"][textarea memo="←freetext" memo_size="small" cols="80" rows="2"] [comment memo="↓quickpicks↓" memo_size="small"][checkbox value="mood changes|depression|anxiety|panic attacks|insomnia|hypersomnolence|attention issues|alcohol use|substance use"][/conditional]



[text name="name" memo="Patient name" size="20"] presents for evaluation and continued medication management and psychotherapy. They were last seen on [date name="variable_27" default="1/1/23"] and [checkbox value="no changes were made to the patients medication during the last visit |the following medication changes were made during that visit: "][textarea memo="other" default="" rows="1"]. 
Today, [var name="name"] [select value="presents with new symptoms of| presents with worsening symptoms of|denies new or worsening symptoms|reports improved symptoms of|reports"] [checkbox value="depression|anxiety|sleep disturbance|impulsivity|inattentiveness| poor concentration|attention challenges|impulsivity |mood lability|behavioral disturbance |autism spectrum disorder"][textarea memo="other" default="" rows="1"].

[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="adhd" memo="adhd" value=""][conditional field="depression" condition="(depression).is('')"]
[var name="name"]'s depression is described as [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|inappropriate guilt|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=". Symptoms are exacerbated by |"][text size="20][select value=", and improved by |"][text size="20].
Client rates depression [select value="1|2|3|4|5|6|7|8|9|10"]/10 with 10 being the worst.[textarea memo="Additional Depression information" rows="5"][/conditional]

[conditional field="anxiety" condition="(anxiety).is('')"]
[var name="name"]'s anxiety generally presents as [checkbox value="feeling nervous or on edge|excessive worry|difficulty relaxing|feeling restless|difficulty getting to sleep|difficulty staying asleep|irritability|poor appetite|overeating|panic attacks"][text size="20]. [select value="Anxiety is present |"][select value="present at all times|intermittently present in response to external stressors|in the context of multiple different situations/events such as |primarily in social situations such as "][textarea rows="1"]. [select value="Anxiety occurs |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 worst. [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 presents 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]
[var name="name"]'s progress in achieving treatment goals can best be characterized as [checkbox value="minimal|minimal due to resistance|making some progress|working on goals, but remains symptomatic"][textarea memo="other" default="" rows="1"]. [checkbox name="bene" memo="The patient would  benefit from:" value=""][conditional field="bene" condition="(bene).is('')"]The patient would  benefit from [checkbox value="initiation of psychopharmaceutical intervention|continuation of current medication regimen|adjustments to current medication regimen|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" rows="1"].[/conditional] [checkbox name="barrier" memo="Barriers to Success:" value=""][conditional field="barrier" condition="(barrier).is('')"]Potential barriers for success include [checkbox value="current apprehension to engage in psychopharmaceutical intervention|current apprehension to engage in structured psychotherapy|non-compliance with medications|limited social supports|dysfunctional interpersonal relationships|conflict in interpersonal relationship with partner|peer conflict|financial stressors|trauma reminders|school stressors|life transitions|work related stressors|medication management issues|medication changes|cormorbid physical health issues|grief/loss|lack of financial resources|risk-taking behaviour|unemployment|strained familial relationships"][textarea memo="additional barriers" rows="1"].[/conditional] [checkbox name="str" memo="Strengths to Success:" value=""][conditional field="str" condition="(str).is('')"]The patients strength(s) for success include [checkbox value="expression of willingness to engage in treatment recommendations|positive social supports|strong therapeutic rapport|history of actively engaging in mental-health treatment"][textarea memo="additions strengths" rows="1"].[/conditional]

[var name="name"] [select value="denies wanting medication changes at this time|is open to considering further medication adjustments for the treatment of |is requesting medication adjustments today for treatment of "][text name="variable_1" default=""].[checkbox name="edu" memo="Education Provided" value=""][conditional field="edu" condition="(edu).is('')"] Psychopharmacological education furnished with the patient consenting to [textarea name="variable_1" default=""] [/conditional]

[conditional field="A" condition="(A).is('Followup')"][comment memo="1pt each, 2pt for summary"][/conditional]
[checkbox value="I reviewed the following notes:"][textarea default="" rows="1"][conditional field="A" condition="(A).is('Followup')"][comment memo="
1pt each, 2pts for summary"][/conditional]
[checkbox value="I reviewed the following labs, imaging, consults:"] [textarea default="" rows="1"][conditional field="A" condition="(A).is('Followup')"][comment memo="
1pt each, 2pts for summary"][/conditional]
[checkbox value="I obtained collateral information from: "] [textarea default="" rows="1"][conditional field="A" condition="(A).is('Followup')"][comment memo="
2pts each"][/conditional]
[checkbox value="I consulted with: "][textarea memo="
individual and reason for consultation" default="" rows="1"]
[checkbox value="I reviewed PMP|and found no abnormal results|and found the following abnormal results: "][textarea default="" rows="1"]

PLAN

The patient will [checkbox name="homework"  value="take medication(s) as prescribed|continue regular meetings with current therapist|establish care with an outpatient therapist|maintain sobriety|reflect on psychoeducation topics/materials covered in today's session| engage in journaling/reflective note| create daily routines to encourage self care, behavioral activation, and organization| consistently commit to daily routine/behavioral activation schedule| establish healthy boundaries with friends/family| utilize CBT skills (reframing/challenging/replacing negative thoughts)| engage in mindfulness/stress reduction techniques (deep breathing, meditation, guided imagery)| experiment with at least one new self care activity this week | practice distress tolerance skills| implement coping skills consistently when dysregulated| track mood, and triggers for mood fluctuations| follow safety plan if in crisis"] [text name="variable_a" default=","] [checkbox name="variable_22" value="The following blood work was ordered today:"] [conditional field="variable_1" condition="condition to test"] [text name="variable_99" default="."] [checkbox name="variable_23" value="Updated rating scales sent to the patient via Therapy Notes portal to be completed prior to next visit."] The patient will devise a regular and adequate eating schedule, a pattern of adequate sleep and relaxation, as well as regular cardiovascular exercise. 
The next appointment is scheduled for date [date name="variable_8" default="12-05-2022"]

PSYCH: * more detail



Patient name presents for evaluation and continued medication management and psychotherapy. They were last seen on and
other.
Today, name
other.

depression anxiety sleep mood adhd


name's progress in achieving treatment goals can best be characterized as
other. The patient would benefit from: Barriers to Success: Strengths to Success:

name . Education Provided






individual and reason for consultation



PLAN

The patient will The patient will devise a regular and adequate eating schedule, a pattern of adequate sleep and relaxation, as well as regular cardiovascular exercise.
The next appointment is scheduled for date

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.59, 140 form elements, 62 boilerplate words, 18 text boxes, 25 text areas, 2 dates, 33 checkboxes, 28 drop downs, 8 variables, 6 comments, 20 conditionals, 252 total clicks
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