Psychiatry
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approximately 119 views since I made an informed decision.
Subjective:
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_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"].
[textarea name="variable_6" default="sample text"]
Allergies:
[text name="variable_1" default="sample text"]
Medication
[textarea name="variable_1" default="sample text"]

Objective:
Vitals:
[textarea name="variable_1" default="sample text"]

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 therapist: [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="retardation|agitation|none"].
Speech: [select name="variable_12" value="normal rate/normal volume|spontaneous|impoverished|pressured|aphasic|emotional|monotonous"].
Thought process: [select name="variable_13" value="linear, goal-directed, coherent|disorganized|incoherent|flight of ideas|racing thoughts|loose associations|perseverative|tangential|spontaneous"].
Thought Content: [text name="variable_14" default="sample text"].
Mood: [text name="variable_15" default="sample text"].
Affect: [select name="variable_25" value="congruent with mood, stable|blunted|flat|incongruent with mood"].
Perception: [select name="variable_16" value="No Hallucinations|Audio Hallucinations|Visual Hallucinations|Tactile Hallucinations|Olfactory Hallucinations|preocuppied with delusions|preocuppied with thoughts"].
Suicidal Ideation: [select name="variable_17" value="none present|passive ideation, no plans or intent|activally 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"]

Assessment:
[textarea name="variable_21" default="sample text"]

Multi-Axial Assessment
Summary: This is the documentation system for diagnosis of psychiatric illness.

Axis I: Psychiatric Illness
[textarea default="Such as Major Depression, Anxiety Disorder, Obsessive Compulsive Disorder, or Bipolar Disorder"]

Axis II: Chronic Developmental Disorders and Personality Disorders
[textarea default="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"]

Highest GAF in the last year
[select name="Q2" 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:
Patient was scheduled for an appointment on [text name="variable_22" default="sample text"].
Prognosis: At the time of writing, patient's prognosis is [select name="variable_23" value="good|fair|poor|uncertain"] and continued treatment is [select name="variable_24" value="recommended|not recommended|Cdsds"].
[textarea name="variable_1" default="sample text"]

[calc value="score1=(A)+(B)"]
Subjective:
Patient reports things have been since the last visit.
Neurovegetative Symptoms: sleep is ; appetite is ; energy levels are ; concentration is .

Allergies:

Medication


Objective:
Vitals:


Mental Status Examination
Alert and Oriented:
Appearance: .
Attitude toward the therapist: .
Eye contact: .
Psychomotor activity: .
Speech: .
Thought process: .
Thought Content: .
Mood: .
Affect: .
Perception: .
Suicidal Ideation: .
Homicidal Ideation:
Insight: .
Judgement:

Assessment:


Multi-Axial Assessment
Summary: This is the documentation system for diagnosis of psychiatric illness.

Axis I: Psychiatric Illness


Axis II: Chronic Developmental Disorders and Personality Disorders


Axis III: Physical Conditions


Axis IV: Psychosocial Stressors


Axis V: Global Assessment of Functioning (GAF)
Current GAF


Highest GAF in the last year

display/hide references

Plan:
Patient was scheduled for an appointment on .
Prognosis: At the time of writing, patient's prognosis is and continued treatment is .


score1=(A)+(B)

Result - Copy and paste this output:

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