SOAP 3
S: Patient reports things have been [select name="variable_1" value="getting better|getting worse|just about the same"] since the last visit. Neurovegetative Symptoms: sleep is [select name="variable_1" value="Good|Fair|Poor|Terrible|Not discussed"]; appetite is [select name="variable_1" value="Good|Fair|Poor|Terrible|Not discussed"]; energy levels are [select name="variable_1" value="Good|Fair|Poor|Terrible|Not discussed"]; concentration is [select name="variable_1" value="Good|Fair|Poor|Terrible|Not discussed"]. [textarea name="variable_1" default="sample text"] O: MSE Alert and Oriented: [select name="variable_1" value="x4|x3|x2|x1"] Appearance: [select name="variable_1" value="Appropriately dressed/well groomed|disheveled|inappropriately dressed|neglected"]. Attitude toward the therapist: [select name="variable_1" value="cooperative|guarded|suspicious|paranoid|paranoid|warm"]. Eye contact: [select name="variable_1" value="Good|Fair|Poor|Fleeting|Avoidant"]. Psychomotor activity: [select name="variable_1" value="retardation|agitation|none"]. Speech: [select name="variable_1" value="normal rate/normal volume|spontaneous|impoverished|pressured|aphasic|emotional|monotonous"]. Thought process: [select name="variable_1" value="linear, goal-directed, coherent|disorganized|incoherent|flight of ideas|racing thoughts|loose associations|perseverative|tangential|spontaneous"]. Thought Content: [text name="variable_1" default="sample text"]. Mood: [text name="variable_1" default="sample text"]. Affect: [select name="variable_1" value="congruent with mood, stable|blunted|flat|incongruent with mood"]. Perception: [select name="variable_1" value="No Hallucinations|Audio Hallucinations|Visual Hallucinations|Tactile Hallucinations|Olfactory Hallucinations|preocuppied with delusions|preocuppied with thoughts"]. Suicidal Ideation: [select name="variable_1" value="none present|passive ideation, no plans or intent|activally suicidal"]. Homicidal Ideation:[select name="variable_1" value="no homicidal ideation|current homicidal ideation"] Insight: [select name="variable_1" value="good|fair|poor"]. Judgement: [select name="variable_1" value="good|fair|poor"] A: [textarea name="variable_1" default="sample text"] P: Patient was scheduled for an appointment on [text name="variable_1" default="sample text"]. Prognosis: At the time of writing, patient's prognosis is [select name="variable_1" value="good|fair|poor|uncertain"] and continued treatment is [select name="variable_1" value="recommended|not recommended|Cdsds"]. [textarea name="variable_1" default="sample text"]
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0.77, 26 form elements, 71 boilerplate words, 3 text boxes, 3 text areas, 20 drop downs, 26 total clicks
More SOAPnotes by this Author:
Send Feedback for this SOAPnote