Soap psych #2

Psychiatry & Psychology
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HISTORY OF PRESENTING PROBLEM[comment memo="
99212 requires 1 HPI
99213 requires 1 HPI + pertinent ROS
99214 requires 4 HPI + pertinent ROS plus one other + 1 P/F/S hx
99215 requires 4 HPI + complete ROS + 2 P/F/S hx"]

*Chief Complaint*
Date and Time of Service:[date default="today"] [text size="8"]
Patient presents today for a follow-up evaluation. Patient presents with a chief complaint of
"[textarea memo="quotes" default="" rows="1"]"

Last visit [comment memo="LAST VISIT"][checkbox value="the following changes were made to patient's treatment: |no changes were made to patient's treatment plan"][textarea memo="other" default="" rows="1"]. Patient[checkbox value=" endorses new symptoms of| endorses worsening symptoms of|denies new or worsening symptoms|reports improved symptoms of"][textarea memo="other" default="" rows="1"]. Patient reports onset of this symptom began [textarea memo="onset" default="" rows="1"]. Patient reports the following precipitating events and/or stressors: [textarea memo="cause" default="" rows="1"]. The patient has noticed the following exacerbating factors: [comment memo="Exacerbating factors "][checkbox value="isolation|reminders of past|lack of control|conflict with others"][textarea memo="other" default="" rows="1"]. However, the patient also notices that it is improved by: [comment memo="Modifying factors "][checkbox value="talking to someone|being alone|doing something physical like walking|doing something that is distracting"][textarea memo="other" default="" rows="1"]. Associated symptoms include:[comment memo="Associated symptoms "][checkbox value="irritability|mood instability|heightened anxiety|attention problems|insomnia|fearfulness|nightmares|alcohol cravings|opiate cravings"][textarea memo="other" default="" rows="1"]. Patient reports their depression is a [select name="depression" value="0|1|2|3|4|5|6|7|8|9|10"]; reports their anxiety is a [select name="anxiety" value="0|1|2|3|4|5|6|7|8|9|10"]; reports their cravings are a [select name="cravings" value="0|1|2|3|4|5|6|7|8|9|10"]; and reports they are sleeping on average [select name="sleep" value="0|1|2|3|4|5|6|7|8|9|10"] hours per night. Patient [comment memo="side effects"][checkbox value="denies medication side effects|endorses medication side effects"][textarea memo="other" default="" rows="1"].

*Review of Systems* [comment memo="Include for 99213 thru 99215"]
Currently in Therapy:
[select value="denied|currently in "] [textarea rows="1"]
Current Suicidal Ideation:
[select value="denied|yes with no plan|yes with a plan|not suicide but thoughts of being better off dead"][checkbox value="contracts for safety|cannot contract for safety"] [textarea rows="1"]
Scales and Screening:
PHQ-9: [select value="unable to assess | ||declined|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30| |"]
GAD-7: [select value="| |unable to assess|declined|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30| |"][conditional field="A" condition="(A).is('Intake')"]
MDQ: [select value="negative|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30| |"]
HITS:[select value="negative|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30| |"]
PC-PTSD:[select value="negative|unable to assess|declined|1|2|3|4| |"]
AUDIT:[select value="negative|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30| |"]
DAST-10:[select value="negative|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30| |"]
SLUMS:[select value="N/A|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30| |"]
[/conditional]
*Review of Systems* [conditional field="A" condition="(A).is('Followup')"][comment memo="Include for 99213 thru 99215"][/conditional]
The patient identifies the following symptoms: [comment memo="Pertinent System "][checkbox value="irritability|mood instability|heightened anxiety|attention problems|troubled by hallucinations|fearfulness|nightmares|alcohol cravings|opiate cravings"] [textarea memo="other" default="" rows="1"]
Other systems:
Neurological - [checkbox value="Headaches|weakness|disturbed sleep|denied"] [textarea memo="other" default="" rows="1"]
GI - [checkbox value="Upset stomach|nausea|constipation|heatburn|denied"] [textarea memo="other" default="" rows="1"].
All other systems negative
*Past/Family/Social History* [conditional field="A" condition="(A).is('Followup')"][comment memo="Include for 99214 + 99215
Consider Substance use, Social/Family Supports, Current medication, Housing, Financial, Legal"]
[textarea rows="3"][/conditional]
[conditional field="A" condition="(A).is('Intake')"]
Current Substance Use:
[select value="Denied|N/A|Reports positive for "][checkbox value="alcohol|tobacco|cannabis|opiate use|methamphetamine use"] [textarea rows="1"]
Social Supports:
[checkbox value="none|significant other|extended family|children|friends|church members"][textarea rows="1"]
Marital status:
[select value="married|partnered|single|"][textarea rows="1"]
Children:
[select value="0|1|2|3|4|5|6|7|"][textarea rows="1"]
Lives:
[select value="with significant other|alone|with children|with extended family|with parents|"][textarea rows="1"]
Works:
[select value="on disability|retired|unemployed|works as a |"][textarea rows="1"]
Financial Concerns:
[select value="none|related to healthcare costs|related to supporting family|"][textarea rows="1"]
Source of Income:
[select value="disability|social security|unemployment|work|family support|"][textarea rows="1"]
Housing Concerns:
[select value="none|unstable housing situation related to |"][textarea rows="1"]
Spirituality:
[select value="Christian|Catholic|Muslim|Jewish|Spiritual but not practicing|Athiest|Agnostic|"][textarea rows="1"]
Sexual Orientation:
[select value="heterosexual|homosexual|bisexual|declined to answer|unable to assess due to symptomatic presentation|"][textarea rows="1"]
Military:
[select value="denied|retired |active |"][textarea rows="1"]
Legal Concerns:
[select value="denied|reports positive for "][textarea rows="1"]


*Past/Family/Social History* [comment memo="Include for 99214 + 99215"]
[textarea rows="3"]

PHYSICAL EXAMINATION [comment memo="
99212 requires 1
99213 requires 6
99214 requires 9
99215 requires ALL"]


Appearance: [select value="stated age|older than stated age|younger than stated age"], [select value="neat|disheveled"][textarea memo="other" default="" rows="1"]
Gait and Station / Muscle Strength and Tone: [select value="Steady gait while walking, normal strength bilaterally|"][checkbox value="unsteady gait while walking|clumsy|unable to ambulate|in bed|in wheelchair|rigid|normal strength bilaterally|weakness noted in "][textarea memo="other" default="" rows="1"]
Mood and Affect:
Mood- [checkbox value="euthymic|depressed|anxious|angry|irritable|happy|fluctuating"][textarea memo="other" default="" rows="1"]
Affect- [checkbox value="sad|tearful|labile|anxious|flattened|restricted|irritable|happy|full range"][textarea memo="other" default="" rows="1"]
Speech: [select value="Normal rate and rhythm, not pressured|pressured|paucity|soft"][textarea memo="other" default="" rows="1"]
Thought process: [select value="logical, linear, age appropriate|circumstantial|"][textarea memo="other" default="" rows="1"]
Associations: [select value="intact|loose|tangential|"][textarea memo="other" default="" rows="1"]
Thought Content: [select value="no evidence of delusions, |"][select value="no evidence of response to internal stimuli, |"][select value="no suicidal ideation or intentions, |"][select value="no homicidal ideation or intentions|"][textarea memo="other" default="" rows="1"]
Orientation: [select value="Oriented to person, place, and time|unable to assess due to cognitive impairment|"][textarea memo="other" default="" rows="1"]
Attention and Concentration: [select value="Adequate attention and concentration based on answers to interview questions|unable to assess due to cognitive impairment|impaired attention and concentration as evidenced by |"][textarea memo="other" default="" rows="1"]
Memory: [select value="Recent and remote memories both intact based on patient's answers to interview questions|unable to assess due to cognitive impairment"][textarea memo="other" default="" rows="1"]
Language: [select value="No evidence of aphasia |"][select value="|, able to name objects|[select value="|, able to repeat phrases"][select value="|unable to assess due to cognitive impairment"][textarea memo="other" default="" rows="1"]
Judgment and Insight:
Judgment- [select value="fair|good|poor|impulsive"][textarea memo="other" default="" rows="1"]
Insight- [select value="fair|good|poor"][textarea memo="other" default="" rows="1"]
Fund of Knowledge: Based on the answers to interview questions, patient's intelligence is judged to be [select value="average|above average|below average|unable to assess due to cognitive impairment"][textarea memo="other" default="" rows="1"]


REVIEW/MANAGEMENT
*Problem Status*[comment memo="
Problem status: Established-stable/improved=1pt each
Established-worsening=2pt each
New problem, no additional workup planned=3pt (only one)
New problem, additional workup planned=4pt"]
The patient's progress in achieving treatment goals can best be characterized as: [checkbox value="minimal|patient is resistant|patient is making some progress|patient is working on goals, but remains symptomatic"][textarea memo="other" default="" rows="1"]
Current Psychiatric Medications:
[textarea rows="4"]
*Data Reviewed*
[comment memo="1pt each, 2pt for summary"][checkbox value="I reviewed the following notes:"][textarea default="" rows="1"][comment memo="
1pt each, 2pts for summary"][checkbox value=" I reviewed the following labs, imaging, consults: "][textarea default="" rows="1"][comment memo="
1pt each, 2pts for summary"][checkbox value=" I obtained collateral information from "][textarea default="" rows="1"][comment memo="
2pts each"][checkbox value=" I consulted with "][textarea memo="individual and reason for consultation" default="" rows="1"][checkbox value="I reviewed PMP|and found no abnormal results.|and found abnormal results "][textarea default="" rows="1"]

*Management*[comment memo="
Risk/Morbidity/Mortality
Low (99213)= One stable chronic illness/Two or more slef-limited or minor problems
Moderate (99214)= Prescription meds; chronic illness with mild exacerbation or side effects of treatment; 2 or more stable chronic illnesses
High (99215)= Psychiatric illness with potential threat to self or others, drug therapy requiring intensive monitoring for toxicity; one or more chronic illnesses with severe exacerbation, progression, or side effects of treatment"]
The following interventions were ordered/recommended this appointment:
[textarea rows="5"]

ASSESSMENT
Patient is currently displaying [select value="symptoms of|well managed|moderately managed|poorly managed"] [checkbox value="depression|anxiety|sleep disturbance|psychosis|substance use disorder|cognitive impairment|impulsivity|mood lability|alcohol dependence|opioid dependence|autism spectrum disorder"][textarea memo="other" default="" rows="1"] which is [select value="likely caused by|likely exacerbated by|likely the result of"] [checkbox value="their substance use disorder|their trauma history|their depressive disorder|their anxiety disorder|their bipolar disorder|interpersonal/family conflict|the stressors of a rigorous substance use program|maladaptive behaviors|poor psychosocial support systems"][textarea memo="other" default="" rows="1"]. Patient would benefit from [checkbox value="continued psychopharmaceutical intervention|adjustments to current psychopharmaceutical intervention|continuation of current psychotherapy|engaging in grief therapy|engaging in CBT|engaging in family therapy|enhanced psychosocial supports|increasing personal time and self-care"][textarea memo="other" rows="1"]. Prognosis is [select value="good|fair|poor"] considering the patient [select value="remains adherent to|actively engages in|is not currently responding to"] medication/therapy to address [textarea memo="target of treatment" rows="1"][checkbox value=" and whether they are able to engage constructively with social supports"]. [checkbox value="Barriers to success include: "][checkbox value="current apprehension to engage in psychotropic intervention|current apprehension to engage in structured substance use treatment|current emotional distress due to unresolved trauma|limited social supports|dysfunctional interpersonal relationships|poor insight"][textarea memo="barriers" rows="1"]. [checkbox value="Patient strength for success include: "][checkbox value="expression of willingness to engage in treatment recommendations|positive social supports|are well connected with outpatient supports|history of actively engaging in mental-health treatment|high intelligence"][textarea memo="strengths" rows="1"]. [textarea rows="5"]

PLAN:
[textarea rows="5"]to treat [checkbox value="mood lability|depression|anxiety|cravings|insomnia|trauma symptoms|hallucinations|paranoia|compulsions"][textarea memo="other" default="" rows="1"]
[textarea rows="5"]
[checkbox value="I discussed risks vs. benefits, as well as side effects with the patient, reviewed alternative treatments, including no treatment, and answered any questions. "][checkbox value="Medications have been discussed with parents or legal guardians. "][checkbox value="The patient and/or parent or legal guardian received medication information in the form of a medication information handout. "]

Labs ordered? [checkbox value="no|yes, CBC, CMP, thyroid panel, Vit. B, Vit. D, lipid panel"][textarea memo="other" default="" rows="1"]

Follow-up in
[checkbox name="variable_1" value="2 weeks|4 weeks|Emergency referral|Refill medications| Continue in therapy"]
HISTORY OF PRESENTING PROBLEM
99212 requires 1 HPI
99213 requires 1 HPI + pertinent ROS
99214 requires 4 HPI + pertinent ROS plus one other + 1 P/F/S hx
99215 requires 4 HPI + complete ROS + 2 P/F/S hx


*Chief Complaint*
Date and Time of Service:
Patient presents today for a follow-up evaluation. Patient presents with a chief complaint of
"quotes"

Last visit LAST VISIT other. Patient other. Patient reports onset of this symptom beganonset. Patient reports the following precipitating events and/or stressors:cause. The patient has noticed the following exacerbating factors: Exacerbating factors other. However, the patient also notices that it is improved by: Modifying factors other. Associated symptoms include:Associated symptoms other. Patient reports their depression is a ; reports their anxiety is a ; reports their cravings are a ; and reports they are sleeping on average hours per night. Patient side effects other.

*Review of Systems* Include for 99213 thru 99215
Currently in Therapy:

Current Suicidal Ideation:

Scales and Screening:
PHQ-9:
GAD-7:
*Review of Systems*
The patient identifies the following symptoms: Pertinent System other
Other systems:
Neurological - other
GI - other.
All other systems negative
*Past/Family/Social History*

Current Substance Use:

Social Supports:

Marital status:

Children:

Lives:

Works:

Financial Concerns:

Source of Income:

Housing Concerns:

Spirituality:

Sexual Orientation:

Military:

Legal Concerns:



*Past/Family/Social History* Include for 99214 + 99215


PHYSICAL EXAMINATION
99212 requires 1
99213 requires 6
99214 requires 9
99215 requires ALL



Appearance: , other
Gait and Station / Muscle Strength and Tone: other
Mood and Affect:
Mood- other
Affect- other
Speech: other
Thought process: other
Associations: other
Thought Content: other
Orientation: other
Attention and Concentration: other
Memory: other
Language: other
Judgment and Insight:
Judgment- other
Insight- other
Fund of Knowledge: Based on the answers to interview questions, patient's intelligence is judged to be other


REVIEW/MANAGEMENT
*Problem Status*
Problem status: Established-stable/improved=1pt each
Established-worsening=2pt each
New problem, no additional workup planned=3pt (only one)
New problem, additional workup planned=4pt

The patient's progress in achieving treatment goals can best be characterized as: other
Current Psychiatric Medications:

*Data Reviewed*
1pt each, 2pt for summary
1pt each, 2pts for summary

1pt each, 2pts for summary

2pts each
individual and reason for consultation

*Management*
Risk/Morbidity/Mortality
Low (99213)= One stable chronic illness/Two or more slef-limited or minor problems
Moderate (99214)= Prescription meds; chronic illness with mild exacerbation or side effects of treatment; 2 or more stable chronic illnesses
High (99215)= Psychiatric illness with potential threat to self or others, drug therapy requiring intensive monitoring for toxicity; one or more chronic illnesses with severe exacerbation, progression, or side effects of treatment

The following interventions were ordered/recommended this appointment:


ASSESSMENT
Patient is currently displaying other which is other. Patient would benefit from other. Prognosis is considering the patient medication/therapy to addresstarget of treatment . barriers. strengths.

PLAN:
to treat other



Labs ordered? other

Follow-up in

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