SUD initial intake

CHIEF COMPLAINT: This is an initial medical assessment on [text name="person1" default=""] who is being voluntarily admitted for medically managed detox and subsequent residential services for:[checkbox name="sud" value="alcohol use disorder|amphetamine use disorder|cannabis use disorder|sedative,hypnotic,anxiolytic use disorder| opioid use disorder| cocaine use disorder| other stimulant use disorder| hallucinogens use disorder| substance use of inhalants| substance use of other psychoactive substances and multiple drug use|polysubstance use"]
[checkbox memo="precipitating event" name="precipitating_event" value=""][conditional field="precipitating_event" condition="(precipitating_event).is('')"]as evidence by patient's statement,"[text name="variable_precep" default=""][/conditional]
[checkbox memo="context of" name="context_of" value=""][conditional field="context_of" condition="(context_of).is('')"] in the context of[text name="variable_context" default=""][/conditional]
_______________________________________________
HISTORY OF PRESENT ILLNESS:
[text name="person1" default=""] is a [text default="" size=2]-year-old [select RACE="variable_2020" value="Caucasian|African American|Asian|Hispanic|Multi-Racial|Native Hawaiian| Other not Listed"], [select name="GENDER" value="male|female|transgender male|transgender female|intersex| non-binary"], admitted to NPNE on [date name="variable_datead" default=" "] for treatment related to ongoing and excessive use of 
[checkbox name="sud" value="alcohol use disorder|amphetamine use disorder|cannabis use disorder|sedative,hypnotic,anxiolytic use disorder| opioid use disorder| cocaine use disorder| other stimulant use disorder| hallucinogens use disorder| substance use of inhalants| substance use of other psychoactive substances and multiple drug use|polysubstance use"]
[textarea name="pmhsuds" default="This patient has been engaging in regular use of ---substance-- since the age of --. This patient currently consumes --- daily. Their last use was: --. This patient recalls no history of sobriety/ This patient recalls their history of sobriety occurring --. They have| have not been in other treatment facilities... This patient notes their pattern of substance use has affected relationships, ADLs, coping skills, and finances. This patient's motivation for treatment includes--. BAC on admission 0.--. CIWA on admission --"]
[checkbox memo="include cravings rating" name="include_cravings" value=""][conditional field="include_cravings" condition="(include_cravings).is('')"]This patient reports their cravings are [select name="cravings" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10|high|variable|low|consistent|managable"][/conditional]
[checkbox memo="include detox info" name="include_detox" value=""][conditional field="include_detox" condition="(include_detox).is('')"] Patient reports withdrawal symptoms as [checkbox name="withsx" value="anxiety|fatigue|shivering|seizures|hallucinations|confusion|chills|malaise|nausea|vomitting|paliptations|chest pain|shortnes of breath|sweating|headaches|irritability|agitation|memory loss|hallucinations|hypertension|muscle aches| tactile disturbances|paranoia|depression| sweats|tremors|diarrhea|constipation|abdominal cramping|fuzzy thinking|denies withdrawal symptoms"][/conditional]
[select value="Patient does not have a history of seizure or DTs| Patient has a history of seizure or DTs |"][textarea name="variable_seizureconcerns" default=""]
_______________________________________________________________________________
PAST MEDICAL HISTORY:
[checkbox name="negpmh" value="Patient denies any significant past medical history or current concerns"]
[textarea name="pmhmed" default=" Comorbid conditions include: "]
Patient denies a history of stroke, seizures, MI, dysrhythmias, heart disease, DVT/PE, kidney disease, pancreatitis, liver disease, COPD, cancer, DM, or thyroid disease. VSS and patient is not in acute distress.
[checkbox memo="female only" name="If_female" value=""][conditional field="If_female" condition="(If_female).is('')"] OB/GYN HISTORY: 
LMP: [date name="3" default=""]
[select name="preg" value="Patient is not seeking to get pregnant in the next year| Patient is seeking to get pregnant within the next year"]
Birth control methods:[select name="bc" value="none|oral contraceptives|IUD|barrier method| implanted device|depo-provera|insertable hormone device| hysterectomy"][/conditional]
_______________________________________________________________________________
PAST SURGICAL HISTORY:
[checkbox name="negsurg" value="Patient denies any significant surgical history "]
[textarea name="pastsurg" default=" "]  
_______________________________________________________________________________
[checkbox memo="Psych History" name="psych_hx" value=""][conditional field="psych_hx" condition="(psych_hx).is('')"] PSYCHIATRIC HISTORY:
• Previous psychiatric inpatient treatment: [text name="psych_tx" default="none"]
• Presence or history of suicidal ideation or attempt: [select name="sihx" value="none|yes, present|yes, history"] [text name="sihx" default=""]
• Presence or history of homicidal ideation or attempt: [select name="hihx" value="none|yes, present|yes, history"] [text name="hihx" default=""]
• Presence or history of violence to others (in the last 6 month): [select name="vihx" value="none|yes, present|yes, history"] [text name="vihx" default=""]
• Presence or history of depression: [select name="dephx" value="none|yes, present|yes, history"] [text name="dephx" default=""]
• name="sihx" default=""]
• Presence or history of anxiety: [select name="anxhx" value="none|yes, present|yes, history"] [text name="anxhx" default=""]
• Presence or history of mania: [select name="manhx" value="none|yes, present|yes, history"] [text name="mahx" default=""]
• Presence or history of ADHD symptoms:[select name="adhdhx" value="none|yes, present|yes, history"] [text name="adhdx" default=""]
• Presence or history of racing thoughts: [select name="racehx" value="none|yes, present|yes, history"] [text name="racehx" default=""]
• Presence of history of mood swings: [select name="moodhx" value="none|yes, present|yes, history"] [text name="moodhx" default=""]
• Presence or history of hallucinations: [select name="hallhx" value="none|yes, present|yes, history"] [text name="hallhx" default=""]
• Presence or history of paranoia/ delusional thinking: [select name="parahx" value="none|yes, present|yes, history"] [text name="parahx" default=""]
• Presence or history of PTSD: [select name="ptsdhx" value="none|yes, present|yes, history"] [text name="ptsdhx" default=""]
• Presence or history of OCD: [select name="ocdhx" value="none|yes, present|yes, history"] [text name="ocdhx" default=""]
• Presence or history of eating disorder: [select name="eathx" value="none|yes, present|yes, history"] [text name="eathx" default=""] 
CURRENT PSYCHIATRIC STATUS:
[comment memo="DEPRESSION:"]Patient reports their depression is a [select name="depression" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10|high|variable|low|consistent|managable"]; reports their anxiety is a [select name="anxiety" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10|high|variable|low|consistent|managable"]; reports [select name="diet" value="good|fair|poor|nutrient deficient"] diet. This patient reports they are sleeping on average [select name="sleep" value="0|1|2|3|4|5|6|7|8|9|10"] hours per night with [select name="sleepprob" value="no difficulties|difficulties falling asleep| difficulties with frequent awakenings|difficulties staying asleep| difficulties with nightmares"] flight of ideas, increased goal-directed activities, rapid or increased speech, thoughtlessness| Patient confirms without demonstration of symptoms of mania: distractability, irritability, grandiosity, flight of ideas, increased goal-directed activities, rapid or increased speech, thoughtlessness"]
MEDICATIONS:
• [select name="psychmeds" value="|Current medications include:|Trialed medications include:|There are no current or trialed medications"][text name="psychmedsex" default=""][/conditional]
_______________________________________________________________________________
PSYCHOSOCIAL HISTORY:
• LEGAL HISTORY: [textarea name="legal" default="Denies any current or past history of jail/prison, probation/parole, charges or pending charges."]
• TRAUMA HISTORY: [select value="No history of head injuries or traumatic brain injuries|Past history of traumatic brain injuries resulting from |Patient has an underlying cognitive impairment from |"] [textarea rows="2"]. [select value="Denies history of trauma (sexual, emotional or physical)|Reported having a history of trauma (sexual, emotional or physical) but did not want to elaborate|Reported past traumatic experiences to include |"][textarea rows="2"].
• FAMILY CONSTELLATION/SUPPORT: Patient has [select value="no|1|2|3|4|5|6|7|"] [select name="householdppl" value="children|pets|"]. Patient is [select name="variable_status" value="single|married|partnered|divorced|separated|widowed"]
• RESIDENCE: [select name="res2" value="independently|with family|with children| with partner| with roommates| homeless| transient| shelter-based| residing with friends or family as short term guest| residential facility| nursing home| refugee| correctional facility| mobile home"]
• SOCIAL SUPPORT: Patient identifies [checkbox value="having no one|significant other|family|neighbors|extended family|children|friends|church members"][textarea rows="1"] as social-support network.
• COMMUNITY SUPPORT:[text name="communitysup" default=""]
• EDUCATION: Highest level of education is [select value="high school|an undergraduate degree |a graduate degree in |some high school|some college|currently in grade school|currently in grad school"].
• FINANCIAL SUPPORT: Patient is [select value="unemployed|currently on disability due to mental health condition|currently on disability due to medical condition|currently on disability|currently employed |currently retired|"]
_______________________________________________________________________________
FAMILY MEDICAL HISTORY:
Medical: [textarea name="freefhx" default="|Patient denies a family history of diabetes, cancer, thyroid issues, heart disease, hypertension, lung diseases, kidney problems, genetic disorders, stroke, MSK disorders, neurological disorders"]
Psych:[textarea name="psychfmh" default=""]
Substance Use:[textarea name="sudfmh" default=""]
_______________________________________________________________________________
HISTORY OF COMMUNICABLE DISEASES:    
•Patient [select name="std" value="denies|endorses|does not disclose"] current concerns about STDs and Hep C 
•History of MRSA/VRE: [select name="MRSA" value="no|yes|unknown"]
•History of TB: [select name="TB" value="no|yes|unknown"]
•COVID SCREENING: Denies fever, fatigue, cough, SOB, chest pain, diarrhea, and sick contacts. No recent travel outside state or to foreign countries.      
VACCINE STATUS:     
COVID: [select name="COVID" value="yes|no|unknown"]
Influenza: [select name="flu" value="yes|no|unknown"]
_______________________________________________________________________________
ROS: 12-point system reviewed; Pertinent negatives and positives discussed in HPI.
_______________________________________________________________________________
PHYSICAL EXAMINATION   
GENERAL: well-appearing, cooperative, well-nourished, in NAD    
DERM: No open wounds or abrasions. Skin warm and dry. Capillary refill in fingers <2 seconds.     
HEAD: Normocephalic, atraumatic.    
EENT:  PERRLA, EOMI, pupils 3mm, sclera and conjunctiva without erythema or injection. Vision grossly normal and gaze aligned appropriately, oral mucosa and gums pink and moist, no pharyngeal or tonsillar exudate, uvula midline. No sinus tenderness. No dental abscesses seen.  Unable to assess: EACs & Bilateral TMs.
NECK: supple
CV: RRR, S1 & S2 clear, without m/r/g.  No peripheral or generalized edema. +2 pulses in upper and lower extremities.     
RESP: lung fields clear bilaterally. Respirations even and regular. No use of accessory muscles. Air entry normal.     
GI: Soft, non-tender, non-distended. BS present x 4. No masses. No hepatosplenomegaly.     
GU:  No bladder distention. Genital exam deferred r/t asymptomatic.    
MSK: Bilateral upper/lower extremities: symmetric, adequate muscle tone with 5/5 muscle strength, full ROM.  No CVA tenderness.     
NEURO: A & O x 3. Stable gait and coordination. CN II-XII intact. Patellar Reflexes: 2+ bilaterally, bilateral normal sensation to all extremities
PSYCH/MSE:
--General/Appearance: [select name="variable_3" value="well kempt|poorly kempt|appropriately dressed|inappropriately dressed|appropriately groomed|inappropriately groomed| appears stated age| appears older than stated age| appears younger than stated age"].
--Sensorium:[select name=_variable_2_ value=_alert and oriented in all spheres|obtunded|disoriented|disoriented|fatigued]
--Behavior - general: [select name="variable_4" value="in no acute distress|in acute psychological distress"].
--Behavior - stability: [select name="variable_5" value="calm|agitated|neutral"].
--Behavior - interactivity: [select name="variable_6" value="polite and cooperative|interactive|withdrawn|hostile|questioning|demanding|agitation present"].
--Behavior - eye contact: [select name="variable_7" value="eye contact good|eye contact fair|eye contact avoidant"].
--Mood/Affect: [select name="variable_8" value="normal|upbeat|euthymic|depressed|dysthmic|neutral|anxious|hostile|irritable|tearful"].
--Mood/Affect - emotional range: [select name="variable_9" value="normal|broad|restricted"].
--Mood/Affect - intensity: [select name="variable_10" value="normal|expansive|blunted|flat"].
--Mood/Affect - congruence: [select name="variable_11" value="mood is congruent with affect|mood and affect are not congruent"].
--Thought form and content: [select name="variable_12" value="normal|future oriented|logical, linear and goal-oriented|past oriented and somber|goal directed|scattered|hopeful|remorseful|enthusiastic|resigned|tangential|circumstantial"]
--Attention: [select name="variable_13" value="no difficulty with attention or concentration|had some attentional and concentration problems during the exam"].
--Perception - insight: [select name="variable_14" value="normal insight|poor insight"]
--Perception- general: [select name="variable_15" value=normal|normal - denied any preoccupations, obsessions, delusions, mania, hallucinations or perceptual disturbances| abnormal- endorses preoccupations, obsessions, delusions, mania, hallucinations or perceptual disturbances| observed preoccupations, obsessions, delusions, hallucinations, mania or perceptual disturbances"]
--Cognition/Memory: [select name="variable_16" value="normal|grossly intact|below average|above average|abnormal|deterioration"].
--Cognition/Memory - abstraction: [select name="variable_17" value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"]
--Judgment: [select name="variable_18" value="normal|poor|good"].
--Suicide/Assault: [select name="variable_19" value="no current or past ideation or intent|denies an active sense of wanting to harm self or others|present but without intent or plan|resolved"].
_______________________________________________________________________________
LABS COLLECTED ON ADMISSION:
CBC, CMP, TSH, UA, Urine Drug Screen
[text name="labtest" default="Other tests:"]
_______________________________________________________________________________
ASSESSMENT/PLAN
Reason for Admission: This patient is here for voluntary admission for medically managed withdrawal and recovery. During this stay, this patient will be provided education and support during recovery in a protected environment.    
_______________________________________________________________________________
ACTIVE PROBLEMS/MEDICAL PLAN:
1.[checkbox name="sud2" value="alcohol use disorder|amphetamine use disorder|cannabis use disorder|sedative,hypnotic,anxiolytic use disorder| opioid use disorder| cocaine use disorder| other stimulant use disorder| hallucinogens use disorder| substance use of inhalants| substance use of other psychoactive substances and multiple drug use"] [checkbox name="continued" value="Continue [checkbox name="detoxdrug" value="Librum per protocol| Ativan per protocol|Suboxone per protocol| Valium per protocol| Ativan PRN per protocol"]
- Monitor s/s for withdrawal    
- Provide PRN medications as indicated
- Educate on the withdrawal process, detox protocol, medication management, and side effects
- Encourage to engage in group sessions, individual therapy sessions, and outings per treatment plan
- Coordinate treatment with the psychiatric team
- Encourage to engage in ongoing relapse prevention and aftercare plan
- Continue to monitor during detox and recovery in a protected environment
- Pending labs for admission
[checkbox name="nalt" value="[checkbox name="viv" value="Educated on naltrexone and vivitrol"]
_______________________________________________________________________________
#.[checkbox name="nic" value="Nicotine Use Disorder"]
[checkbox name="cess" value="[select name="variable_4" value="Cessation Date planned for stay. Behavioral options for quitting reviewed. NRT in place| Behavioral and Pharmacological options for quitting were reviewed. Does not wish to quit at this time"]
_______________________________________________________________________________
#.[select name="HTN" value=" |Hypertension|Elevated BP without a dx of HTN"]  
[checkbox name="htnplan" value="Monitor vital signs daily. This patient is going through acute withdrawal from ETOH therefore pt blood pressure will be labile. (Goal for Blood Pressure is Blood pressure less than 60 year old less than 140 over 80 (with or without diabetes CKD) greater than 60 years old less than 150 over 90)"]
[checkbox name="htnmed" value="Continue Medication"][text name="htnmed" default=" "]
_______________________________________________________________________________
#.[comment memo="OTHER MEDICAL CONDITIONS-PLANS"]
[textarea name="variable_MED" default=""]
_______________________________________________________________________________
#.[comment memo="OTHER PSYCH CONDITIONS-PLANS"]
[textarea name="variable_psychconplan" default=""]
_______________________________________________________________________________
#.[select name="BMI" value=" |BMI"]  
[checkbox name="variable_bmi" value="Encourage moderate daily exercise and healthy eating habits (high water, fiber, and lean protein) (reduce caloric intake Women 1200-1500kcal/day men 1500-1800 day)drink non-sugar, non-caffeinated beverages|LAB ORDER: Glucose, Hemoglobin A1c, Total Cholesterol, HDL Cholesterol, Triglycerides, Non-HDL, and Calculated Components"]
_______________________________________________________________________________
#. [select name="stdhr" value="||High Risk Sexual Behavior"]
-[checkbox name="variable_stdhr" value="R/F include multiple partners, new partners, unprotected sexual encounters, known + partners|Testing for G/C (urine/ swab), HIV, Hep C, RPR, BV, Herpes (blood, swab)"]
-[link url="https://www.mdcalc.com/denver-hiv-risk-score" memo="Denver High Risk Score"][text name="stdhr" default=" "]
_______________________________________________________________________________
#. [select name="sxhx" value="||Seizure History"]
-[checkbox name="variable_sxhxr" value="Medications Rx'd to aid with alcohol withdrawal seizures. Nursing to monitor CIWAs and Vitals. If a seizure were to occur then acute management of the seizure should be concomitant with ABCs, avoiding hazards, and monitoring vital signs & glucose monitoring. Nursing advised to call provider if this occurs; call EMS if decompensation occurs"]
_______________________________________________________________________________
#. [select name="sxsicurrent" value="||Suicidal Ideation"]
-[checkbox name="variable_sxsicurrent" value="Patient is determined to be at __risk for suicide. Interventions include daily monitoring of suicidal ideation and every 15-minute rounding for safety. Nursing advised to immediately contact the provider if there is an escalation in suicidality"]
_______________________________________________________________________________MEDICAL CLEARANCE:
This patient is medically cleared to participate in therapeutic programming as tolerated.
[textarea name="variable_1" default="If not, why"]CONTINUING PROBLEM LIST:
[textarea name="PROBLEMLIST" default="It is recommended that this patient should establish care and/or follow up with PCP after discharge regarding health maintenance and preventative health guidelines for ages 19-64 years "]
CHIEF COMPLAINT: This is an initial medical assessment on who is being voluntarily admitted for medically managed detox and subsequent residential services for:
precipitating event
context of
_______________________________________________
HISTORY OF PRESENT ILLNESS:
is a -year-old , , admitted to NPNE on for treatment related to ongoing and excessive use of


include cravings rating
include detox info

_______________________________________________________________________________
PAST MEDICAL HISTORY:


Patient denies a history of stroke, seizures, MI, dysrhythmias, heart disease, DVT/PE, kidney disease, pancreatitis, liver disease, COPD, cancer, DM, or thyroid disease. VSS and patient is not in acute distress.
female only
_______________________________________________________________________________
PAST SURGICAL HISTORY:


_______________________________________________________________________________
Psych History
_______________________________________________________________________________
PSYCHOSOCIAL HISTORY:
• LEGAL HISTORY:
• TRAUMA HISTORY: . .
• FAMILY CONSTELLATION/SUPPORT: Patient has . Patient is
• RESIDENCE:
• SOCIAL SUPPORT: Patient identifies as social-support network.
• COMMUNITY SUPPORT:
• EDUCATION: Highest level of education is .
• FINANCIAL SUPPORT: Patient is
_______________________________________________________________________________
FAMILY MEDICAL HISTORY:
Medical:
Psych:
Substance Use:
_______________________________________________________________________________
HISTORY OF COMMUNICABLE DISEASES:    
•Patient current concerns about STDs and Hep C 
•History of MRSA/VRE:
•History of TB:
•COVID SCREENING: Denies fever, fatigue, cough, SOB, chest pain, diarrhea, and sick contacts. No recent travel outside state or to foreign countries.      
VACCINE STATUS:     
COVID:
Influenza:
_______________________________________________________________________________
ROS: 12-point system reviewed; Pertinent negatives and positives discussed in HPI.
_______________________________________________________________________________
PHYSICAL EXAMINATION   
GENERAL: well-appearing, cooperative, well-nourished, in NAD    
DERM: No open wounds or abrasions. Skin warm and dry. Capillary refill in fingers <2 seconds.     
HEAD: Normocephalic, atraumatic.    
EENT:  PERRLA, EOMI, pupils 3mm, sclera and conjunctiva without erythema or injection. Vision grossly normal and gaze aligned appropriately, oral mucosa and gums pink and moist, no pharyngeal or tonsillar exudate, uvula midline. No sinus tenderness. No dental abscesses seen.  Unable to assess: EACs & Bilateral TMs.
NECK: supple
CV: RRR, S1 & S2 clear, without m/r/g.  No peripheral or generalized edema. +2 pulses in upper and lower extremities.     
RESP: lung fields clear bilaterally. Respirations even and regular. No use of accessory muscles. Air entry normal.     
GI: Soft, non-tender, non-distended. BS present x 4. No masses. No hepatosplenomegaly.     
GU:  No bladder distention. Genital exam deferred r/t asymptomatic.    
MSK: Bilateral upper/lower extremities: symmetric, adequate muscle tone with 5/5 muscle strength, full ROM.  No CVA tenderness.     
NEURO: A & O x 3. Stable gait and coordination. CN II-XII intact. Patellar Reflexes: 2+ bilaterally, bilateral normal sensation to all extremities
PSYCH/MSE:
--General/Appearance: .
--Sensorium:
--Behavior - general: .
--Behavior - stability: .
--Behavior - interactivity: .
--Behavior - eye contact: .
--Mood/Affect: .
--Mood/Affect - emotional range: .
--Mood/Affect - intensity: .
--Mood/Affect - congruence: .
--Thought form and content:
--Attention: .
--Perception - insight:
--Perception- general:
--Cognition/Memory: .
--Cognition/Memory - abstraction:
--Judgment: .
--Suicide/Assault: .
_______________________________________________________________________________
LABS COLLECTED ON ADMISSION:
CBC, CMP, TSH, UA, Urine Drug Screen

_______________________________________________________________________________
ASSESSMENT/PLAN
Reason for Admission: This patient is here for voluntary admission for medically managed withdrawal and recovery. During this stay, this patient will be provided education and support during recovery in a protected environment.    
_______________________________________________________________________________
ACTIVE PROBLEMS/MEDICAL PLAN:
1.
- Monitor s/s for withdrawal    
- Provide PRN medications as indicated
- Educate on the withdrawal process, detox protocol, medication management, and side effects
- Encourage to engage in group sessions, individual therapy sessions, and outings per treatment plan
- Coordinate treatment with the psychiatric team
- Encourage to engage in ongoing relapse prevention and aftercare plan
- Continue to monitor during detox and recovery in a protected environment
- Pending labs for admission

_______________________________________________________________________________
#.

_______________________________________________________________________________
#.  


_______________________________________________________________________________
#.OTHER MEDICAL CONDITIONS-PLANS

_______________________________________________________________________________
#.OTHER PSYCH CONDITIONS-PLANS

_______________________________________________________________________________
#.  

_______________________________________________________________________________
#.
-
-Denver High Risk Score
_______________________________________________________________________________
#.
-
_______________________________________________________________________________
#.
-
_______________________________________________________________________________MEDICAL CLEARANCE:
This patient is medically cleared to participate in therapeutic programming as tolerated.
CONTINUING PROBLEM LIST:

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