SOAP 2020

Chief Complaint: [textarea name="variable_31" default= ""]
Subjective: 
Patient reports things have been [select name="variable_1" value="getting better|getting worse|just about the same"] since the last visit.
Symptoms: sleep is [select name="variable_2" value="Good|Fair|Poor|Terrible|Not discussed"]; appetite is [select name="variable_3" value="Good|Fair|Poor|Terrible|Not discussed"]; energy levels are [select name="variable_4" value="Good|Fair|Poor|Terrible|Not discussed"]; concentration is [select name="variable_5" value="Good|Fair|Poor|Terrible|Not discussed"].

Informant: [textarea name="variable_30" default= ""]
Justification for admission: Safety and Stabilization 
History of Present Illness
[textarea name="variable_6" default= "-------Denies depressive symptoms of sleeplessness, loss of interest, guilty feeling, poor concentration, decrease energy or appetite and psychomotor symptoms. Denies paranoia, audio or visual hallucination and homicidal and suicidal ideation. Denies any present of manic symptoms of distractibility, irritability, grandiosity, rapid or pressured speech, impulsive behavior or agitation. Patient currently denies any intent or plan to harm self or others."]

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

Medication
[textarea name="variable_1" default=""]
Family history:[text name="variable_8" default=""]  
Social history:[text name="variable_9" default=""] 
Medical history:[text name="variable_10" default=""] 
Alcohol/Drug Use:[text name="variable_11" default=""] 
Past psychiatric history:[text name="variable_12" default="Hospitalization?"]
Legal Concern: [text name="variable_58" default= ""]

Objective: 
Vitals:
B/P [text name="variable_2" default=""] mmHg
HR [text name="variable_3" default=""] bpm
Resp. [text name="variable_4" default=""] rpm
Ht. [text name="variable_5" default=""] in
Wt. [text name="variable_6" default=""] lbs.
BMI [text name="variable_7" default=""]

Mental Status Examination
Alert and Oriented: [select name="variable_7" value="x4|x3|x2|x1"]
Appearance: [select name="variable_8" value="Appropriately dressed/well groomed|disheveled|inappropriately dressed|neglected"].
Attitude toward the interview: [select name="variable_9" value="cooperative|guarded|suspicious|paranoid|paranoid|warm"].
Eye contact: [select name="variable_10" value="Good|Fair|Poor|Fleeting|Avoidant"].
Psychomotor activity: [select name="variable_11" value="none|agitation|retardation"].
Speech: [select name="variable_12" value="normal rate/normal volume|spontaneous|impoverished|pressured|aphasic|emotional|monotonous|slow|loud|soft"].
Thought process: [select name="variable_13" value="linear, goal-directed, coherent|disorganized|incoherent|flight of ideas|racing thoughts|loose associations|perseverative|tangential|spontaneous|word salad"].
Thought Content: [select name="variable_26" value="absence of delusional or obsessional thinking|delusion|guilty|future oriented|fears|ruminative ideas"].
Mood: [select name="variable_27" value="euthymic|dysphoric|apathetic|depressed|hypomanic|manic|irritable|mixed"].
Affect: [select name="variable_25" value="congruent with mood, stable|blunted|flat|restricted|incongruent with mood"].
Perception: [select name="variable_16" value="No Hallucinations|Audio Hallucinations|Visual Hallucinations|Tactile Hallucinations|Olfactory Hallucinations|preoccupied with delusions|preoccupied with thoughts"].
Suicidal Ideation: [select name="variable_17" value="none present|passive ideation, no plans or intent|actively suicidal"].
Homicidal Ideation:[select name="variable_18" value= "no homicidal ideation|current homicidal ideation"]
Insight: [select name="variable_19" value="good|fair|poor"].
Judgement: [select name="variable_20" value="good|fair|poor"]
Cognition/Memory: [select name="variable_54" value="normal|grossly intact|below average|above average"].
Cognition/Memory - abstraction: [select name="variable_52" value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"]

Assessment:
[textarea name="variable_21" default="sample text"]
Summary: This is the documentation system for diagnosis of psychiatric illness.

Axis I: Psychiatric Illness
[textarea default="-Major Depressive Disorder, -Generalized Anxiety Disorder, Obsessive Compulsive Disorder, Bipolar Disorder, Alcohol Use Disorder or Substance Use Disorder"]

Axis II: Chronic Developmental Disorders and Personality Disorders
[textarea default="-Deferred -Developmental disorders includes Autism and Mental Retardation; Personality disorders include Paranoid, Antisocial, and Borderline Personality Disorders, among others"]

Axis III: Physical Conditions
[textarea default="Physical conditions such as brain injury or HIV/AIDS that can result in symptoms of mental illness"]

Axis IV: Psychosocial Stressors
[textarea default="Events in a person's life, such as death of a loved one, starting a new job, college, unemployment, and marriage"]

Axis V: Global Assessment of Functioning (GAF)
Current GAF
[select name="Q1" value="91-100: Higher level functioning in broad range of activities with good and control of typical life stressors|81-90: Other than mild psychiatric symptoms for common triggers, good level of functioning|71-80: Mild psychiatric symptoms with triggers and mild impact on functioning|61-70: Mild psychiatric symptoms with impact on functioning, but overall functioning is good and relationships are maintained|51-60: Moderate psychiatric symptoms with moderate impact on functioning|41-50: Serious symptoms and impaired functioning|31-40: Impaired reality and major Impairment|21-30: Delusions, hallucinations, or serious Impairment|11-20: Danger to self or others|1-10: Persistent danger to self or others"]

[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference:
[link url="//psychiatryonline.org/" memo="#1"] Diagnostic and Statistical Manual of Mental Disorders
[/conditional]
Plan:
Treatment is [select name="variable_24" value="recommended|not recommended|Cdsds"].
The following interventions were ordered/recommended this appointment:
[textarea name="variable_11" default="Intervention needed, Current medication to initiate and/or continue, Referral to psychotherapy, Social Planning (Housing/Disability), Time frame for next follow up for reassessment, -Admit to impatient for stabilization 
-Will start antipsychotic and mood stabilizer
-Monitor medication compliance and side effect 
-Milieu, group, psycho-education, and supportive therapy will be provided"]

I discussed risks vs. benefits, as well as side effects with the patient, reviewed alternative treatments, including no treatment, and answered any questions. Plan of care reviewed with patient and agreed with current regimen.  Patient advised if any homicidal or suicidal ideation to call 911 or go to the nearest ER. 


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