SOAP PT 3

[textarea name="variable_1" default="sample text"][text name="variable_1" default="sample text"]

Subjetivo
Paciente vem    à    consulta    [select name="acompanhamento" value="sozinho|com    familiar|com    amigo|"] [text name="variable_1" default="sample text"].  Relata, [textarea name="problem" default=""]  Consultou inicialmente para tratamento de [textarea name="primaryconcern" default="ADHD, anxiety, depression, PTSD, adjustment issues, marriage concerns." rows="2"] continua relatando sintomas consistentes com {DIAGNÓSTICO},[checkbox name="Depressão1" memo="Depressão" value=""][checkbox name="Ansiedade1" memo="Ansiedade" value=""][checkbox name="Panico" memo="Panico" value=""][checkbox name="ADHD1" memo="ADHD" value=""][checkbox name="PTSD1" memo="PTSD" value=""][checkbox name="Bipolar1" memo="Bipolar Disorder" value=""][checkbox name="Insomnia" memo="Insomnia" value=""][checkbox name="Alcohol1" memo="Alcohol Use" value=""][checkbox name="AdjustmentDisorder1" memo="Adjustment Disorder" value=""] [conditional field="Depressão1" condition="(Depressão1).is('')"] Depressão is reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|little interest or pleasure in doing things|hopelessness|helplessness|sleeping too much|difficulty falling asleep|difficulty staying asleep|feeling tired or having little energy|poor appetite|overeating|feelings of guilt and inadequacy|irritability|poor concentration|psychomotor retardation|psychomotor agitation|suicidal ideation"].[textarea memo="Additional information" rows="1"][/conditional] [conditional field="Anxiety1" condition="(Anxiety1).is('')"] Anxiety is reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|feeling restless/wound up|fatigue|difficulty concentrating|irritability|difficulty falling asleep|difficulty staying asleep|feeling tired or having little energy|muscle tension|headaches|feeling overwhelmed|poor concentration|loss of appetite"].[textarea memo="Additional information" rows="1"][/conditional] [conditional field="Panic1" condition="(Panic1).is('')"] Panic symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|palpitations/racing heart|sweating|shortness of breath|chest pain/tightness|nausea/stomach cramps|numbness/tingling|fear of losing control|closed in feeling|feeling overwhelmed|heat sensations|trembling/shaking"].[textarea memo="Additional information" rows="1"][/conditional] [conditional field="ADHD1" condition="(ADHD1).is('')"] ADHD symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|inattention|careless mistakes|difficulty sustaining attention|problems following conversations|easily side tracked|difficulty organizing tasks/activities|avoidance and procrastination|forgetfulness|easily distracted by unrelated thoughts|fidgeting|inability to relax|excessive talking|difficulty waiting/reduced patience"].[textarea memo="Additional information" rows="1"] [/conditional][conditional field="PTSD1" condition="(PTSD1).is('')"] PTSD symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|nightmares|flashbacks|intrusive memories/thoughts|avoidance|negative affect|loss of interest|isolation|difficulty experiencing positive emotions|irritability|easily annoyed|risky/self destructive behaviors|hypervigilance|heightened startle reaction|difficulty concentrating|difficulty falling asleep|difficulty staying asleep"].[textarea memo="Additional information" rows="1"][/conditional] [conditional field="Bipolar1" condition="(Bipolar1).is('')"] Bipolar symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|elevated mood|irritable mood|increased self esteem|loss of sleep|racing thoughts|difficulty keeping up with thoughts|increased desire to speak|feeling more distracted|feeling more energetic|increased desire to engage in activities|agitation|impulsive behaviors|feeling more social/outgoing|increased sex drive|spending money|using drugs/alcohol"].[textarea memo="Additional information" rows="1"][/conditional] [conditional field="Insomnia" condition="(Insomnia).is('')"] Insomnia symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|difficulty falling asleep|difficulty staying asleep|early morning awakening|nightmares|vivid dreams|thrashing in sleep|sleep walking|daytime sedation/fatigue|sleep talking|night terrors|confusion|sleep related eating|hallucinations going to sleep|hallucinations when waking up"].[textarea memo="Additional information" rows="1"][/conditional] [conditional field="Alcohol1" condition="(Alcohol1).is('')"] Alcohol use symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of alcohol use|daily drinking|drinking more than anticipated|inability to cut down on drinking|cravings to drink|blackouts|hangovers|urges to drink|missing work due to drinking|drinking alone|drinking and driving|drinking to fall asleep|escalating alcohol use|tremors|nausea|vomiting|headaches|sweating|anxiety|racing heart|confusion|visual hallucinations|auditory hallucinations|seizures"].[textarea memo="Additional information" rows="1"][/conditional] [conditional field="AdjustmentDisorder1" condition="(AdjustmentDisorder1).is('')"] Adjustment disorder symptoms are [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="marked distress that is disproportionate to the severity/intensity of stressor|significant impairment in social, occupational, and other areas of functioning|depressed/low mood|anhedonia|tearfulness|feelings of hopelessness|nervousness|excessive worrying|difficulty concentrating|feeling overwhelmed"].[textarea memo="Additional information" rows="1"][/conditional]
Ongoing mental health treatment at this level is required to mitigate these symptoms and help client achieve desired goals for therapy.

To address client's symptoms and achieve therapeutic goals, focus/themes of session for today include: [checkbox name="Symptomsmanagement" memo="Symptoms/Management" value=""][checkbox name="ADHD" memo="ADHD" value=""][checkbox name="GenderSexuality" memo="Gender/Sexuality" value=""][checkbox name="Other" memo="Other" value=""][checkbox name="Attachmentissues" memo="Attachment issues" value=""][checkbox name="Behavioralhealthissues" memo="Behavioral health issues" value=""][checkbox name="Substanceuse" memo="Substance use" value=""][checkbox name="Trauma" memo="Trauma" value=""][checkbox name="Relationships" memo="Relationships" value=""][checkbox name="Interpersonal" memo="Interpersonal" value=""][checkbox name="Adjustment" memo="Adjustment" value=""][checkbox name="Griefloss" memo="Grief/loss" value=""][checkbox name="Stressors" memo="Stressors" value=""][conditional field="Symptomsmanagement" condition="(Symptomsmanagement).is('')"][checkbox value= "Current symptoms/functioning|Symptom management|Management of depressive symptoms|Management of anxiety symptoms|Emotional dysregulation|Distress intolerance|Anger issues|Mood management|Impacts of symptoms"][/conditional][conditional field="ADHD" condition="(ADHD).is('')"][checkbox value= "ADHD symptoms/diagnosis|ADHD treatment/medications|Self-esteem|Management of executive dysfunction"][/conditional][conditional field="GenderSexuality" condition="(GenderSexuality).is('')"][checkbox value= "Gender identity|Sexual orientation|Coming out process|Reactions from family/friends/others"][/conditional][conditional field="Other" condition="(Other).is('')"][checkbox value= "Homework/assignment follow up|Goals/treatment plan review|Client history/background"][/conditional][conditional field="Attachmentissues" condition="(Attachmentissues).is('')"][checkbox value= "Adult attachment style issues|Attachment anxiety and avoidance|Adult attachment anxiety|Fear of developing intimate relationships|Fear of interpersonal rejection and/or abandonment|Adult attachment avoidance|Fear of intimacy|Excessive need for self-reliance|Distrust of others"][/conditional][conditional field="Relationships" condition="(Relationships).is('')"][checkbox value= "Relationship dissatisfaction|Conflict/argument with partner|Intimacy concerns|Infidelity/affair concerns|Child custody conflict|Codependency issues|Divorce issues|Trust concerns|Communication problems with partner|Breakup/acute relationship concerns|Abuse/IPV|Relationship trauma|Previous relationship issues"][/conditional][conditional field="Adjustment" condition="(Adjustment).is('')"][checkbox value= "Adjustment to stressor(s)|Adjustment to workplace changes|Adjustment to job loss/change|Adjustment to relationship changes|Adjustment to family life changes|Adjustment to a developmental event"][/conditional][conditional field="Griefloss" condition="(Griefloss).is('')"][checkbox value= "Death of a family member|Death of a friend|Grief reactions|Processing past regrets|Processing grief|Processing a death/loss"][/conditional][conditional field="Interpersonal" condition="(Interpersonal).is('')"][checkbox value= "Interpersonal conflict(s)|Conflict with friends|Conflict with family of origin|Conflict within nuclear family|Conflict with partner/spouse|Conflict with coworker(s)|Communication issues|Poor boundary setting/People pleasing|Difficulty saying no to others|Passive behaviors|Aggressive behaviors"][/conditional][conditional field="Behavioralhealthissues" condition="(Behavioralhealthissues).is('')"][checkbox value= "Self-care activities|Sleep difficulty/concerns|Nutrition/eating habits|Physical activity/exercise|Daily scheduling|Energy levels"][/conditional][conditional field="Substanceuse" condition="(Substanceuse).is('')"][checkbox value= "Substance use concerns|Alcohol use concerns|Cannabis use concerns|Tobacco use concerns|Relapse prevention"][/conditional][conditional field="Trauma" condition="(Trauma).is('')"][checkbox value= "Family of origin dynamics|Past trauma event|Recent trauma event|Sexual trauma event|Childhood trauma|Past childhood abuse/neglect|Past distressing memory"][/conditional][conditional field="Stressors" condition="(Stressors).is('')"][checkbox value= "Life stressors|Stressor/coping mechanism(s)|Family dysfunction|Work problems|School problems|Bullying|Work-related stress|Negative work environment|Difficulty with work/life balance|Financial issues|Legal issues|Housing issues|Relationship issues|Parenting stress/issues"][/conditional]

OBJECTIVE
Client is aware of how the telehealth appointment will proceed; agreement to a communication back up plan if connection fails; client is aware of the risks and limitations of telehealth appointment; suitable electronic connection has been established; client is satisfied with the level of privacy of current environment; client’s identity has been established; client fits within therapist’s scope for telehealth. Client is oriented x3, mental status and functioning appear to be WNL. Client's observed affect is [textarea name="MSE" default="full, flat, blunted, labile, tearful, appropriate, inappropriate, restricted and client reported their mood to be euthymic, depressed, anxious, irritable, angry, sad, elevated. Client's observed behavior and appearance both appropriate. Client denied A/V hallucinations."]

Measures completed and scores: 
[checkbox name="00" value="None"][checkbox name="PHQ" value= "PHQ9"][conditional field="PHQ" condition="(PHQ).is('PHQ9')"][text name="score1" default=""][/conditional][checkbox name="GAD" value= "GAD7"][conditional field="GAD" condition="(GAD).is('GAD7')"][text name="score2" default=""][/conditional][checkbox name="PCL" value= "PCL5"][conditional field="PCL" condition="(PCL).is('PCL5')"][text name="score3" default=""][/conditional][checkbox name="DES1" value= "DES"][conditional field="DES1" condition="(DES1).is('DES')"][text name="score4" default=""][/conditional][checkbox name="SCARED1" value= "SCARED"][conditional field="SCARED1" condition="(SCARED1).is('SCARED')"][text name="score5" default=""][/conditional][checkbox name="ASRS1" value= "ASRS1.1"][conditional field="ASRS1" condition="(ASRS1).is('ASRS1.1')"][text name="score6" default=""][/conditional]

ASSESSMENT

Progress:
Treatment goals addressed this session include [textarea name="goals" default="reducing overall level, frequency, and intensity of anxiety, improving/developing coping skills, reducing symptoms of depression, reducing symptoms of PTSD, improving overall mood, coping with routine life stressors, improving executive functioning skills, improving quality of interpersonal relationships, resolving issues related to traumatic event, processing grief/loss, learning effective communication strategies." rows="6"] Client is open to interventions, motivated to progress in treatment, and engaged in discussion with therapist throughout. [comment memo="Client response"] Client is [textarea name="response" default="responding well to interventions/making good progress, making slow progress, making intermittent progress, maintaining progress, regressing/worsening."] [comment memo="Client strengths"] The client demonstrates [textarea name="strengths" default="regular utilization of effective coping strategies, improved insight into their responses and natural/conditioned ways of thinking, increased capability to appropriately identify and express emotions, improved capacity for emotion regulation, improvement in tolerance for frustration, increased capability to tolerate painful feelings, increased capacity to show compassion for themself, improvement in ability to manage and respond appropriately to symptoms, positive adjustments to their mindset and former distortions."] [comment memo="Client challenges"] Client continues to experience challenges with [textarea name="challenges" default="recognizing/labeling emotions, expressing thoughts and feelings, managing and responding appropriately to symptoms, regularly utilizing coping skills, utilizing effective communication skills, executive functioning skills, emotional/affect regulation, sleep, social functioning/relationships, practicing personal hygiene/self care,"] which continue to negatively and significantly impact the client's quality of life.
In order to alleviate/reduce symptoms of [textarea name="necessary" default="depression, anxiety, trauma, mood disorder, ADHD" rows="2"] and improve functioning, it is necessary for client to remain engaged in current level of care/services. 

PLAN
Client opted to schedule a follow up session per current agreed upon treatment frequency of [textarea name="frequency" default="weekly, biweekly, monthly, as needed." rows="2"]

Date of next session:[text name="date" default="XX/XX/23"]

Planned actions for future sessions:

Changes in diagnosis or treatment plan: [text box="changes" value="None"]

Client's overall prognosis is [textarea name= "prognosis" default="good,fair, guarded, poor." rows="2"]


Subjetivo
Paciente vem à consulta . Relata,
Consultou inicialmente para tratamento de
continua relatando sintomas consistentes com {DIAGNÓSTICO}, Depressão Ansiedade Panico ADHD PTSD Bipolar Disorder Insomnia Alcohol Use Adjustment Disorder
Ongoing mental health treatment at this level is required to mitigate these symptoms and help client achieve desired goals for therapy.

To address client's symptoms and achieve therapeutic goals, focus/themes of session for today include: Symptoms/Management ADHD Gender/Sexuality Other Attachment issues Behavioral health issues Substance use Trauma Relationships Interpersonal Adjustment Grief/loss Stressors

OBJECTIVE
Client is aware of how the telehealth appointment will proceed; agreement to a communication back up plan if connection fails; client is aware of the risks and limitations of telehealth appointment; suitable electronic connection has been established; client is satisfied with the level of privacy of current environment; client’s identity has been established; client fits within therapist’s scope for telehealth. Client is oriented x3, mental status and functioning appear to be WNL. Client's observed affect is


Measures completed and scores:


ASSESSMENT

Progress:
Treatment goals addressed this session include
Client is open to interventions, motivated to progress in treatment, and engaged in discussion with therapist throughout. Client response Client is
Client strengths The client demonstrates
Client challenges Client continues to experience challenges with
which continue to negatively and significantly impact the client's quality of life.
In order to alleviate/reduce symptoms of
and improve functioning, it is necessary for client to remain engaged in current level of care/services.

PLAN
Client opted to schedule a follow up session per current agreed upon treatment frequency of


Date of next session:

Planned actions for future sessions:

Changes in diagnosis or treatment plan:

Client's overall prognosis is

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.67, 122 form elements, 243 boilerplate words, 10 text boxes, 20 text areas, 51 checkboxes, 10 drop downs, 3 comments, 28 conditionals, 304 total clicks
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