Weekly/Monthly 19-06a

[select name="TimePeriod" value="Monthly|Weekly #1|Weekly #2|Weekly #3|Weekly #4|Weekly #5|Weekly #6|Weekly #7|Weekly #8"]

CLINICAL SUMMARY
IDENTIFICATION:[comment memo="paste identification in below"]
[textarea name="Identification"][/textarea]

OBSERVATIONS PER STAFF AND PATIENT:
[textarea name="PatientProgress" rows=10 default="The patient was seen and interviewed throughout this time period. I reviewed the chart and nursing reports and discussed the patient’s status with the treatment team."][/textarea]

[textarea rows=10]Rapport with staff and patients: Patients has not had any issues with peers and has been cooperative with staff.
Significant Behavioral Events: No extra meds, restraints, or significant behavioral issues reported
Medical Concerns: No significant changes
[/textarea]

[textarea name="StaffReports3" default="Today he was seen "][comment memo="(Anything from the interview)"]

MENTAL STATUS EXAM
[checkbox name="app" value="Patient has"][conditional field="app" condition="(app).is('Patient has')"] [checkbox name="appearance" value="good hygiene|fair hygiene|marginal hygiene|poor hygiene|and is well-groomed|adequate grooming|marginal grooming|poor grooming"][text name="hygiene2" default="."][/conditional] [checkbox name="beh" value="His behavior is"][conditional field="beh" condition="(beh).is('His behavior is')"] [checkbox name="cooperation" value="cooperative|uncooperative|somewhat cooperative|superficially cooperative"], [checkbox name="behavior2" value="Aggressive physically|aggressive verbally|argumentative|avoidant|resistant|impulsive|intrusive|withdrawn|hyperactive|hypervigilant|mute|self-injurious|sexually inappropriate|sedated|pleasant|unremarkable"][text name="behavior3" default="."][/conditional] [checkbox name="ec" value="Eye contact is"][conditional field="ec" condition="(ec).is('Eye contact is')"] [checkbox name="eye_contact" value="appropriate|unremarkable|minimal|intense"][text name="eyecontact" default="."][/conditional] [checkbox name="pm" value="His psychomotor activity is"][conditional field="pm" condition="(pm).is('His psychomotor activity is')"] [checkbox name="psychomotor" value="calm|agitated|pacing|slowed|shows no tics tremors or abnormal movements|fidgety|tremor|rigidity|tics"][text name="psychomotor2" default="."][/conditional] [checkbox name="gait" value="His gait is"][conditional field="gait" condition="(gait).is('His gait is')"] [checkbox name="gait1" value="normal|ataxic|shuffling|unsteady"][text name="gait2" default="."][/conditional] [checkbox name="sp" value="Speech is"][conditional field="sp" condition="(sp).is('Speech is')"] [checkbox name="speech3" value="clear|stuttering|mumbled"], [checkbox name="speech" value="has normal rate|fast|slowed"], and [checkbox name="speech2" value="normal volume|loud|quiet"] [text name="speech5" default="."][/conditional] [checkbox name="md" value="Mood is"][conditional field="md" condition="(md).is('Mood is')"] [checkbox name="mood1" value="euthymic|depressed|happy|anxious|angry|irritable|frustrated|euphoric|labile"][text name="mood2" default="."][/conditional] [checkbox name="af" value="Affect is"][conditional field="af" condition="(af).is('Affect is')"] [checkbox name="affect1" value="stable|irritable|hostile|anxious|fearful|dysphoric|labile|appropriate|somewhat inappropriate|inappropriate|inappropriate laughter|intense|blunted|flat|constricted|expansive"][text name="affect2" default="."][/conditional] [checkbox name="tp" value="His thought process is"][conditional field="tp" condition="(tp).is('His thought process is')"] [checkbox name="TP1" value="goal-directed|logical|organized|disorganized|slowed|flight of ideas|tangential|circumstantial|somewhat circumstantial|loosely associated|positive for blocking|neologism"][text name="TP2" default="."][/conditional] [checkbox name="tc" value="His thoughts show evidence of"][conditional field="tc" condition="(tc).is('His thoughts show evidence of')"] [checkbox name="TC1" value="no delusions, obsessions or compulsions|persecutory delusions|grandiose delusions|paranoid delusions"] [text name="T4" default="."][/conditional] [checkbox name="RF1" value="No suicidal or homicidal thoughts."][text name="RF2"] [checkbox value="Not responding to internal stimuli."][text name="Perception1"] [checkbox value="Alert and oriented."][text name="Cognition1"] His insight is [checkbox name="insight" value="good|fair|improving but still limited|limited|poor"][text name="insight2" default="."] His judgement is [checkbox name="judgement" value="good|fair|improving but still limited|limited|poor"][text name="judgement2" default="."]

MEDICATIONS
PSYCH MEDS:[comment memo="paste medications in below"]
[textarea name="Medication1"]

CURRENT RESPONSE TO MEDICATIONS/RECENT CHANGES:
[textarea name="response"]

CURRENT SIDE EFFECTS/ADVERSE EVENTS:
[textarea default="There were no adverse events, drug-drug, or food interactions seen. There are no side effects observed or reported."]

I have discussed the rationale of medication with the patient and gave education about pros and cons of treatment, potential side effects, importance of compliance, and answered any questions. Labs were reviewed. Patient monitored for abnormal movements. 
[textarea default="Patient is on combination therapy due to poor response to monotherapy. History of compliance problems makes clozapine a poor choice."]

DIAGNOSIS:
[textarea name="Diagnosis1"]

ASSESSMENT/PROGRESS TOWARDS TREATMENT GOALS:
[textarea name="Progress1"]

PLAN:
[textarea name="Plan1"]