Psychiatry
Share
Tweet
Cite
approximately 21 views since the last time your electronic medical record was updated to improve usability.
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_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"]. [checkbox name="Past medical history " value="HTN|Diabetes |Cancer|HIV |HEP C|"]
[textarea name="variable_6" default="sample text"]
O:
MSE
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"].
[checklist name="Delusions" value="Persecutory|Erotomanic|Grandiose|Somatic|Mixed"]
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"]
[checkbox name="All pertinent labs" value="CBC|EEG|UA|B12|Lithium Level|Depakote Level"]


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

P:
Patient will be scene for an appointment [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"]
[checkbox name="Discharge at this time will be " value="today|tomorrow|by end of the week|next week|unknown "]
S:
Patient reports things have been since the last visit.
Neurovegetative Symptoms: sleep is ; appetite is ; energy levels are ; concentration is .

O:
MSE
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:



A:


P:
Patient will be scene for an appointment .
Prognosis: At the time of writing, patient's prognosis is and continued treatment is .

Result - Copy and paste this output:

Send Feedback for this SOAPnote

Your email address will not be published.

More SOAPnotes by this Author: