Short NP note

[date name="variable_1" default="03/26/2022"]

S: SUBJECTIVE DATA (information the patient/caregiver tells you)
Presenting Problem/Chief Complaint:
a statement in quotes describing what the patient needs help with today. Then, provide a focused description of onset, duration, characteristics/severity, associated signs and symptoms for that specific diagnosis, measures used to relieve problem. For new intakes principle symptoms associated with differential diagnoses should be included (always include SIGECAPS for depression)
[textarea name="variable_1" default="Chief compliant/ History of Present Illness"]


Significant events since last visit: Describe any particular occurrences which might impact treatment, which demonstrate progress or decline in functioning
[textarea name="variable_1" default="sample text"]


Response to Treatment: Symptoms that were targeted
[textarea name="variable_1" default="sample text"]


Allergies: 
[text name="variable_1" default="sample text"]

Current listing of psychiatric medications patient is taking
[textarea name="variable_1" default="sample text"]


Non-psychiatric Meds:
Current listing of medications taking for other than psychiatric reasons
[textarea name="variable_1" default="sample text"]

Objective
Vital Signs: 
[textarea name="variable_1" default="sample text"]
A: ASSESSMENT Concise listing of diagnoses using the DSM 5 symptoms and ICD diagnostic codes, data contained in the S and O should support your diagnoses and plan.
I. Primary Differentials Diagnosis
[textarea name="variable_1" default="sample text"]



II. General Medical Conditions
P: PREVENTION/HEALTH EDUCATION/FAMILY EDUCATION:
Indicate prevention information presented (see Guide to Clinical Preventive Services, 2008. AHRQ Publication No. 08-05122, September 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/pocketgd.htm), health education shared with client, or family educational material. Include if patient seems to understand material or any barriers to communication.
CHANGES IN MEDS OR PLAN OF CARE (LABS/FOLLOW UP ITEMS):
[textarea name="variable_1" default="sample text"]

Comments
[text name="variable_1" default="sample text"]


S: SUBJECTIVE DATA (information the patient/caregiver tells you)
Presenting Problem/Chief Complaint:
a statement in quotes describing what the patient needs help with today. Then, provide a focused description of onset, duration, characteristics/severity, associated signs and symptoms for that specific diagnosis, measures used to relieve problem. For new intakes principle symptoms associated with differential diagnoses should be included (always include SIGECAPS for depression)



Significant events since last visit: Describe any particular occurrences which might impact treatment, which demonstrate progress or decline in functioning



Response to Treatment: Symptoms that were targeted



Allergies:


Current listing of psychiatric medications patient is taking



Non-psychiatric Meds:
Current listing of medications taking for other than psychiatric reasons


Objective
Vital Signs:

A: ASSESSMENT Concise listing of diagnoses using the DSM 5 symptoms and ICD diagnostic codes, data contained in the S and O should support your diagnoses and plan.
I. Primary Differentials Diagnosis




II. General Medical Conditions
P: PREVENTION/HEALTH EDUCATION/FAMILY EDUCATION:
Indicate prevention information presented (see Guide to Clinical Preventive Services, 2008. AHRQ Publication No. 08-05122, September 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/pocketgd.htm), health education shared with client, or family educational material. Include if patient seems to understand material or any barriers to communication.
CHANGES IN MEDS OR PLAN OF CARE (LABS/FOLLOW UP ITEMS):


Comments

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Sandbox Metrics: Structured Data Index 0.09, 11 form elements, 220 boilerplate words, 2 text boxes, 8 text areas, 1 dates, 11 total clicks
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