SOAP simplificado

[textarea name="problem" default=""]

[textarea name="problem" default=""]

Subjetivo:
[textarea name="problem" default=""]

History of Presenting Illness:
Client expressed, [textarea name="problem" default=""] Client is a {AGE} year old [select name="gender" value="male|female|non-binary|transgender"] who presented initially for the therapeutic treatment for primary concern of [textarea name="primaryconcern" default="ADHD, anxiety, depression, PTSD, adjustment issues, marriage concerns." rows="2"] Client continues to report symptoms consistent with {DIAGNOSIS},[checkbox name="Depression1" memo="Depression" value=""][checkbox name="Anxiety1" memo="Anxiety" value=""][checkbox name="Panic1" memo="Panic" 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="Depression1" condition="(Depression1).is('')"] Depression 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.

Changes in medication: [text name="medication" default="none reported."]

Care coordination: Client discussed no need for care coordination/release of information at this time.

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
EEM: 
[textarea name="EEM" default="Aparência adequada; alerta; euproséxico; sem alterações evidentes na sensopercepção; memória preservada, inteligência não avaliada; humor eutímico, afeto modulado; pensamento lógico; em fluxo habitual, sem delírios expressos, negando ideação suicida; juizo crítico e insight presentes; conduta colaborativa, normolálico."]

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]

Impressão:
[textarea name="problem" default=""]

Conduta:
[textarea name="problem" default=""]

Plano:
[textarea name="problem" default=""]