SOAP PSYCH 2

[conditional field="A" condition="(A).is('Followup')"][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"][/conditional][conditional field="A" condition="(A).is('Intake')"][comment memo="
Intake = 90792"][/conditional]
[conditional field="A" condition="(A).is('Intake')"][/conditional]
*Chief Complaint*
Date and Time of Service:[date default="today"] [text size="8"]
Patient is see in this [checkbox name="A" value="Intake|Followup"][checkbox name="b" value=" with psychotherapy"] for [checkbox value="depression|anxiety|psychosis|substance abuse|cognitive impairment|impulsivity|mood lability|sleep disturbance|alcohol dependence|opiate dependence|autism spectrum disorder"] [textarea memo="other" default="" rows="1"]
[textarea memo="*QUOTES* *REQUIRED*" default="" rows="8"]
*Interval History*
Patient presents as [comment memo="SYMPTOM"][checkbox value="depressed|anxious|aggressive|impulsive|inattentive|irritable|withdrawn|unable to sleep|delusional|auditory hallucinations|visual hallucinations"] [textarea memo="other" default="" rows="1"]
Which is described as[comment memo="SEVERITY "][checkbox value=" the same as it has been| better| somewhat worse than it has been| significantly worse than it has been"] [textarea memo="other" default="" rows="1"]
It seems to [checkbox value="be very brief in duration|last for awhile then goes away|always be present"]
The patient notices that it is sometimes 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"]
[conditional field="A" condition="(A).is('Intake')"]
History of Presenting Illness:
[textarea rows="6"]
Current Psychiatric Medications: 
[textarea rows="4"]
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"] 
HISTORIES:
[comment memo="All Information below is historical and not to be counted as part of the progress note"]
Previous Psychiatric Medications:
[textarea rows="1"]
Previous Psychiatric Hospitalization (s):
[select value="none|"][textarea rows="1"]
Previous Therapy:
[select value="none|"][textarea rows="1"]
Family History of Substance Use or Psychiatric Illness: 
[textarea rows="4"]
History of Suicide Attempt (s): 
[select value="none|"][textarea rows="1"]
Family History of Suicide Attempt (s) or Completed Suicide: 
[select value="none|"][textarea rows="1"]
History of Abuse:
[select value="none|"][textarea rows="1"]
History of Substance Use: 
[select value="none|"][textarea rows="1"][/conditional]
PHYSICAL EXAMINATION: [comment memo="
99212 requires 1
99213 requires 6
99214 requires 9
99215 requires ALL"]
Vital Signs:
 Temp- [text size="8"]C
 Pulse- [text size="8"]
 BP Systolic- [text size="8"]
 BP Diastolic- [text size="8"]
 Resp- [text size="8"]
 Weight- [text size="8"]kg
 Height- [text size="8"]cm
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 name="c" value="Steady gait while walking, normal strength bilaterally|"][conditional field="c" condition="(c).is('')"]
[checkbox value="steady gait while walking|unsteady gait while walking|clumsy|unable to ambulate|in bed|in wheelchair|assisted by cane|assisted by walker|rigid|spastic|normal strength bilaterally|weakness noted in "][/conditional][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|anxious|flattened|restricted|irritable|happy|full range"][textarea memo="other" default="" rows="1"].
Speech: [select value="Normal rate and rhythm, not pressured|pressured|paucity"][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 |unable to assess due to cognitive impairment|"][checkbox value="able to name objects|able to repeat phrases"] [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"]
[conditional field="b" condition="(b).is(' with psychotherapy')"]
[comment memo="Psychiatric Add On
Psychotherapy/Interactive Complexity/Prior case management
"][checkbox value="Time spent in psychotherapy: "][checkbox value="16-37 min"][comment memo="30 min 90833"][checkbox value="38-52 min"][comment memo="45 min 90836"][checkbox value="53-67 min"][comment memo="60 min 90838"]
[checkbox value="Focus of psychotherapy: "][checkbox value="interpersonal conflict|emotional experience related to diagnosis|identification of coping mechanisms|grief counseling"][textarea memo="other" default="" rows="1"]
[checkbox value="Modality: "][checkbox value="insight oriented|supportive|behavioral modification"][textarea memo="other" default="" rows="1"][/conditional]
REVIEW/MANAGEMENT:
[conditional field="A" condition="(A).is('Followup')"]*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"]
[/conditional]
*Management*[conditional field="A" condition="(A).is('Followup')"][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"][/conditional]
Allergies:
[textarea rows="5"]
Medication List:
[textarea rows="5"]
Diagnosis:[conditional field="A" condition="(A).is('Followup')"][comment memo="Indicate whether diagnosis changed, reason for change, date and time of change
"][/conditional][checkbox value="
Major depressive disorder|recurrent|single episode|mild|moderate|severe|
Generalized anxiety disorder|
PTSD|acute|chronic|
Adjustment Disorder|with depressed mood|with anxiety|with depressed mood and anxiety"]
[textarea rows="5"]
Significant Medical Issues:
[textarea rows="5"]
ASSESSMENT:
[checkbox name="prognosis" value="" memo="Prognosis statement"][conditional field="prognosis" condition="(prognosis).is('')"]Patient is currently displaying [select value="symptoms of|well managed|moderately managed|poorly managed"] [checkbox value="depression|anxiety|sleep disturbance|psychosis|substance abuse|cognitive impairment|impulsivity|mood lability|alcohol dependence|opiate dependence|autism spectrum disorder"][textarea memo="other" default="" rows="1"] [select value="likely caused by|likely exacerbated by|likely the result of"] [checkbox value="their cancer diagnosis|their cancer treatment|their unmanaged depressive disorder|their unmanaged anxiety disorder|their unmanaged bipolar disorder|interpersonal/family conflict|current psychopharmaceutical intervention|current psychotherapy|current psychosocial support systems"][textarea memo="other" default="" rows="1"]. Patient would benefit from [checkbox value="initiation of psychopharmaceutical intervention|continued psychopharmaceutical intervention|adjustments to current psychopharmaceutical intervention|initiation of psychotherapy|continuation of current psychotherapy|engaging in grief therapy|engaging in CBT|engaging in family therapy|enhanced psychosocial supports|increasing personal time and self-care"]. [/conditional][conditional field="prognosis" condition="(prognosis).is('')"]Prognosis is [select value="good|fair|poor"] considering the patient [select value="remains adherent to|actively engages in|is not currently responding to|is not currently willing to engage in recommended|has chronically had poor response 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 name="barrier" value="Barriers to success include: "][/conditional][conditional field="barrier" condition="(barrier).is('Barriers to success include: ')"][checkbox value="current apprehension to engage in psychopharmaceutical intervention|current apprehension to engage in structured psychotherapy|current emotional distress of recent cancer diagnosis|limited social supports|dysfunctional interpersonal relationships"][textarea memo="barriers" rows="1"].[/conditional] [conditional field="prognosis" condition="(prognosis).is('')"][checkbox name="strength" value="Patient strength for success include: "][/conditional][conditional field="strength" condition="(strength).is('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"][textarea memo="strengths" rows="1"].[/conditional] [textarea rows="5"]
GOALS:
[checkbox name="Depression" value="-Patient will report score on PHQ-9 of "][conditional field="Depression" condition="(Depression).is('-Patient will report score on PHQ-9 of ')"][select value="8|5|6|7|8|9|10|11|12|13|14|15"] or less within [select value="3 months|1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"][checkbox name="Anxiety" value="
-Patient will report score on GAD-7 of "] [conditional field="Anxiety" condition="(Anxiety).is('
-Patient will report score on GAD-7 of ')"][select value="8|5|6|7|8|9|10|11|12|13|14|15"] or less within [select value="3 months|1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"][checkbox name="Nicotine" value="
-Patient will reduce nicotine intake by 50% within "][conditional field="Nicotine" condition="(Nicotine).is('
-Patient will reduce nicotine intake by 50% within ')"][select value="1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"][checkbox name="Sleep" value="
-Patient will experience 6+ hours of uninterrupted sleep per night within "][conditional field="Sleep" condition="(Sleep).is('
-Patient will experience 6+ hours of uninterrupted sleep per night within ')"][select value="3 months|1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"][checkbox name="Cognition" value="
-Patient will report impact of cognitive impairment as mild/resolved within "][conditional field="Cognition" condition="(Cognition).is('
-Patient will report impact of cognitive impairment as mild/resolved within ')"][select default="3" value="3 months|1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"]
PLAN:
[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. "]

I, Darrin Gooding PMHNP Student under preceptor supervision obtained a history, conducted a mental status examination of the patient, and developed the plan of care.