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Psychiatry & Psychology
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History and Physical
Laurelwood

Name:
[text name="variable_1" default="sample text"]
DOB:
[text name="variable_1" default="sample text"]
CSN:
MRN:
Date:

Chief Complaint:
[textarea name="variable_1" default="sample text"]

HPI:

The patient is a
[textarea name="variable_1" default="sample text"] year old
[checklist name="variable_1" value="male| female|transgender|male identifying as female|female identifying as male|binary"]with a past medical history of
[checklist name="variable_1" value="Abortion|Alcoholism|Anemia|Arthritis|Asthma|Brain Injury|Cancer, NOS|Chronic Pain|Constipation|COPD|Crohn's Disease|Dental Disorders|Dizziness|Diabetes Mellitus|Drug Dependence|Emphysema|Epilepsy|Fatigue|Fibromyalgia|Hepatitis|Hypertension|HIV Infection|Irritable Bowel Syndrome|Motor Neuron Disease|Obesity|Renal Disease|Sleep Disorder|STD|Stroke/CVA|Tuberculosis|Thyroid Disorders"].

Past psychiatric disorder patient reports:[checkbox value="None|Depression|Anxiety|ADHD|OCD|PTSD|Oppositional Defiant Disorder|Autism Spectrum Disorder|Bipolar Disorder I|Bipolar Disorder II|Schizophrenia|Schizoaffective disorder|Borderline Personality Disorder|Antisocial Personality Disorder|Mood Disorder|Anxiety"]

Patient presented via
[checklist name="variable_1" value="private vehicle|EMS"] Patient presented with
[checklist name="variable_1" value="option family|option friend|sheriff's department"]
due to
[checklist name="variable_1" value="arrest|by 2 part avadavit"]signed by
[textarea name="variable_1" default="sample text"] for
[textarea name="variable_1" default="sample text"].

Patient is a
[select name="variable_1" value="good historian|poor historian"]. At this time, the patient
[select name="variable_1" value="denies|reports"] suicidal ideations, homicidal ideations, auditory hallucinations and visual hallucinations. Lastly, patient denies elevated mood or euphoria that would be a concern for mania.

Historian:
[textarea name="variable_1" default="sample text"]
Quality:
[checklist name="variable_1" value="depressed mood|anxious mood"]
Severity: severe
Timing:
[checklist name="variable_1" value="new onset|
[text name="variable_1" default="sample text"]years|
[text name="variable_1" default="sample text"]"]days
[textarea name="variable_1" default="sample text"]
[checkbox name="variable_1" value="constantly |intermittently
Duration:
[text name="variable_1" default="sample text"]
Context: Scenerio in which symptoms began,[checklist name="variable_1" value="substances| medication noncompliance|other"]
Modifying factors:
[checklist name="variable_1" value="nicotine reduction|medication compliance|working with behavioral therapy|safety of housing|community resources|other"]
Associated signs and symptoms:
[checklist name="variable_1" value="mood liability|impulsivity|suicidality"
[checklist name="variable_1" value="anxiety|difficulty concentrating|irritability|anhedonia|social withdrawal and isolation|crying spells|sleep disturbance|sad mood"]

Treatment Planning:

Patients strengths: [checklist name="variable_1" value="willingness to seak treatment |motivation for treatment/growth|strong support system"]
Patient weaknesses: [checklist name="variable_1" value="homelessness|Lack of financial means|lack of psychosocial support|substance use|lack of motivation for treatment|option low self esteem"]

Treatment Team:***

Progress towards goals:***

Recommended treatment:***

Psychiatric and Medical Review of symptoms~
General/Constitutional:
[checklist name="variable_1" value="reports weight gain|reports weight loss|changes in appetite| fatigue"]Psychiatric: Reports[select value="Denies any hallucinations or delusions.|"][select value="Denies past history of psychotic sx.|Endorses past history of psychotic sx.| Endorses past history of psychotic sx in context of substance abuse.
No clear history of psychosis in the absence of co-occurring substance abuse."]
Depression: [select name="DepROS1” value="Denies any current depressive symptoms|Reports current depressive symptom of"] [checkbox name="depsx” value="sad mood|dysphoric mood|irritability|anhedonia|social withdrawal and isolation|crying spells|sleep disturbance|difficulty falling asleep, w/ delayed onset of sleep up to 1 hour|difficulty falling asleep, w/ delayed onset of sleep of 1 - 2 hours|difficulty falling asleep, w/ delayed onset of sleep greater than 2 hours|middle of night awakening|early morning awakening|moving or speaking so slowly that other people could have noticed|daytime fatigue|loss Of appetite|increased appetite|difficulty concentrating|decreased attention|increased anxiety|ruminative thoughts|feelings of worthlessness|excessive guilt|thoughts of death|mood symptoms are persistent and pervasive, varying little from day to day|depressed mood/sadness most of the time for 2-years or longer "]. [select value="Denies past history of depressive episodes.|Reports past history of depressive episodes."]
Mania: [select name="ManROS1” value="Denies any current manic symptoms.|Reports current manic symptoms of"] [checkbox name="mansx" value="distinct period of abnormally and persistently elevated, expansive or irritable mood|accompanied by persistently increased goal-directed activity or energy|mood disturbance and increased energy/activity has lasted at least one-week and is present most of the day, nearly every day|mood disturbance and increased energy/activity has lasted at least 4 consecutive days and is present most of the day|pressured speech|inflated self-esteem|grandiosity|decreased need for sleep|hyperverbosity|flight of Ideas|subjective racing thoughts|distractiblity|psychomotor agitation|high risk activities"][checkbox value=". Denies behaviors occurred solely in the context of substance abuse.| Reports majority of sx occurred in the context of substance abuse."][select value="Denies past history of manic/hypomanic episodes.|Endorses past history of manic/hypomanic episodes.| Endorses past history of manic/hypomanic episodes in context of substance abuse. No clear history of past manic/hypomanic episodes in the absence of co-occurring substance abuse."]
[textarea name="variable_3" default=""]
HEENT: [checklist name="variable_1" value="dry mouth|involuntary oralfacial movements|headaches|light headedness|nasal congestion|blurred vision|vision changes|sore throat|loss of taste"]
Pulmonary:[checklist name="variable_1" value="shortness of breath|dyspnea on exertion|cough"]
Cardio: Patient [checklist name="variable_1" value=" neither reports or denies chest pain, palpitations, leg swelling"] Patient reports[checklist name="variable_1" value="chest pain|palpitations|leg swelling"]
GI: Patient [checklist name="variable_1" value="neither reports or denies, abdominal pain, diarrhea, constipation, changes in stool, nausea or vomiting|Patient reports|abdominal pain|constipation|diarrhea|changes in stool|weight loss|nausea|vomiting"]
Endocrine: Patient [checklist name="variable_1" value="neither confirms or denies, cold intolerance, polyuria, polydipsia|patient reports|cold intolerance|polydipsia|polyuria|dry skin|hair loss"]
Musculoskeletal: [checklist name="variable_1" value="Patient neither confirms or denies joint pain, swelling, arthralgias, or back pain or weakness|Patient reports| back pain|joint pain|swelling, arthralgias|option weakness|option muscle pain"]
Skin:[checklist name="variable_1" value=" Patient neither confirms or denies changes in skin, pruritus, rash or lesions"]
[checkbox name="variable_1" value="scarring|no scarring"]Patient reports
[checklist name="variable_1" value="pruritis|rash|lesions"]
Neurologic:
[checklist name="variable_1" value="Patient neither confirms or denies light headedness, fainting, seizures, headache, changes in gait or numbness|hx of black outs"]Patient reports [checklist name="variable_1" value="headaches|light headedness|seizures|weakness|numbness|gait changes|hx of black outs"]

Substance Abuse History:
[checklist name="variable_1" value="Patient neither confirms or denies any misuse of subtance's"][checklist name="variable_1" value=" None|Cannabis
[textarea name="variable_1" default="sample text"]|Heroin
[textarea name="variable_1" default="sample text"]|Prescription Pain medication
[textarea name="variable_1" default="sample text"]|Stimulants
[textarea name="variable_1" default="sample text"]|Hallucinogens
[textarea name="variable_1" default="sample text"]|option Cocaine
[text name="variable_1" default="sample text"]
[checkbox name="variable_1" value="option Alcohol"]
[textarea name="variable_1" default="sample text"]|Tobacco
[textarea name="variable_1" default="sample text"]|Caffeine
[textarea name="variable_1" default="sample text"]"]

Tobacco Use Treatment on Admission:
The healthcare provider offered tobacco use cessation on admission and it was received.

Past Psychiatric History:
Previous psychiatric care:Past Outpatient Tx: [checkbox name="past1" memo="Psychiatric provider for medication" value=""] [conditional field="past1" condition="(past1).is('')"][text size=65 default="Psychiatric provider for medication "][/conditional][checkbox name="past2" memo="Psychotherapy/Counseling" value=""] [conditional field="past2" condition="(past2).is('')"][text size=65 default="Psychotherapy/Counseling "][/conditional][checkbox name="past3" memo="Community Mental Health Center" value=""] [conditional field="past3" condition="(past3).is('')"][text size=65 default="Community Mental Health Center "][/conditional][checkbox name="past4" memo="Mental Health Case Management" value=""] [conditional field="past4" condition="(past4).is('')"][text size=65 default="Mental Health Case Management "][/conditional]
Previous psychiatric medications include: [checkbox value="Has taken psych meds before, cannot recall name| Alprazolam (Xanax)| amitriptyline (Elavil)| amoxapine (Asenden)| aripiprazole (Abilify)| Aripiprazole (Abilify Maintena Injectable)| Aripiprazole lauroxil (Aristada Injectable)|asenapine (Saphris)|atomoxetine (Strattera)|benzotropine (Cogentin)| brexpiprazole (Rexulti )| bupropion (Wellbutrin)| buspirone (BuSpar)| carbamazepine (Tegretol)| clonidine for ADHD (Catapres)| chlordiazepoxide (Librium)| chlorpromazine (Thorazine)| citalopram (Celexa)| clomipramine (Anafranil)| clonazepam (Klonopin)| clorazepate (Tranxene)| clozapine (Clozaril)| diphenhydramine (Benadryl)| desipramine (Norpramin)| desvenlafaxine (Pristiq)|amphetamine and dextroamphetamine(Adderall)|Dexedrine)| dexmethylphenidate (Focalin)| diazepam (Valium)| donepezil (Aricept)|doxepin (Sinequan)| duloxetine (Cymbalta)| escitalopram (Lexapro)| folic acid| fluoxetine (Prozac)|fluoxetine + olanzapine (Symbyax)| fluphenazine (Prolixin)| fluphenazine (Prolixin Injectable)| fluvoxamine (Luvox)| gabapentin (Neurontin) for anxiety/mood| galantamine (Razadyne)| guanfacine for ADHD (Intuniv/Tenex)| haloperidol (Haldol)| Haldol Decanoate Injectable| hydroxyzine (Atarax/Vistaril)| imipramine (Tofranil)| L-methylfolate (Deplin)| lamotrigine (Lamictal)| lisdexamfetamine (Vyvanse)| lithium (Lithobid)| Lorazepam (Ativan)| loxapine (Loxitane)| lurasidone (Latuda)| maprotiline (Ludiomil)| melatonin (OTC)| memantine (Namenda)| mesoridazine (Serentil)| methylphenidate (Ritalin/Concerta/Metadate/Daytrana)|milnacipran (Savella)| mirtazapine (Remeron)| modafinil (Provigil)| molindone (Moban)| nefazodone (Serzone)| nortriptyline (Pamelor)| olanzapine (Zyprexa)| Olanzapine pamoate (Zyprexa Relprevv Injectable)| oxazepam (Serax)| oxcarbazepine (Trileptal)| Paliperidone (Invega Sustenna Injectable)| Paliperidone (Invega Trinza Injectable)| paroxetine (Paxil)| pemoline (Cylert)| perphenazine (Trilafon)| phenelzine (Nardil)| prazepam (Centrax)| prazosin (for nightmares)| prochlorperazine (Compazine)| protriptyline (Vivactil)| quetiapine (Seroquel)| risperidone (Risperdal)| Risperidone (Risperdal Consta Injectible)| rivastigmine (Exelon)| selegiline(Emsam)| sertraline (Zoloft)| temazepam (Restoril)| derealization (Mellaril)| topiramate (Topamax)| tranylcypromine (Parnate)| trazodone (Desyrel)| trifluoperazine (Stelazine)| trimipramine) or multiple)| valproic acid (Depakene/Depakote)| venlafaxine (Effexor)| vilazodone (Viibryd)| vortioxetine (Trintellix)| zaleplon (Sonata)| ziprasidone (Geodon)| zolpidem (Ambien)| zopiclone (Lunesta)|"]
[textarea rows="3"]
Previous psychiatric diagnosis:[checkbox value="None|Depression|Major Depression|Anxiety|ADHD|OCD|PTSD|Oppositional Defiant Disorder|Autism Spectrum Disorder|Bipolar Disorder I|Bipolar Disorder II|Schizophrenia|Schizoaffective disorder|Borderline Personality Disorder|Antisocial Personality Disorder|Mood Disorder|Bipolar Disorder|with psychotic features|“bipolar depression”|“bipolar schizophrenia”|Psychotic Disorder|Psychosis NOS|Generalized Anxiety Disorder|Postpartum Depression|Panic Disorder|Adjustment Disorder|Somatoform Disorder|Somatic Symptom Disorder|hx of pseudoseizures|Factitious Disorder|”R/O Factitious Disorder”|Eating Disorder|Anorexia|Bulimia|Borderline Personality Disorder"]
Previous suicidal ideations:
[radio name="variable_1" value="Yes|No"]
Suicide Attempts: [checkbox name="variable_99" value="Denies hx of attempts|No known history|Unable to obtain, none noted upon review of available records|Hx of intentional OD|hx of cutting wrist|hx of attempted hanging|hx of intentional poisoning|hx of attempt with gun|hx of attempt by jumping in front of car"][text name="suicatt" default=""]
Non-Suicidal Self Injurious Behx: [checkbox name="variable_18" value="Denies hx|No known hx|Unable to obtain, none noted upon review of available records|Hx of cutting for tension-release"]
Hx of Violence/Assaultive Behx: [checkbox name="assaulthx" value="Denies hx|None reported|Unable to obtain, none noted upon review of available record"]
Abuse/Trauma: [checkbox value="None|Verbal abuse as child|Physical abuse as child|sexual abuse|witnessing domestic violence|neglect|bullying|domestic violence|assault|death of a loved one"]
Violence:[checkbox value="None|assaultive to siblings|assaultive to parents|assaultive to staff|unprovoked|as a result of limit setting|when psychotic|resulting in significant injury of victim"]

Trauma History: [checkbox name="sextrauma" value="denies history|none reported|sexual abuse in childhood|sexual abuse as adult|history of rape/sexual assault|physical abuse in childhood|physical abuse as adult|witnessed domestic violence in childhood|domestic violence in past relationship|emotional abuse in childhood|emotional abuse as adult|history of being bullied|natural disaster|violent crime |serious accident|serious medical event|combat|crime victim|near death experience|witnessed death"].

Prior Treatment or Therapy inpatient/outpatient:[checklist name="variable_1" value="none|one|multiple admissions|long term state hospital admissions|short term inpatient hospitalizations|crisis unit stays|partial hospitalization program"]
Past Inpatient Tx: [checkbox name="variable_2" value="None|Unable to obtain, none noted on review of available records|No reported treatment on interview, however, chart review indicates |remote history of |past admission to |multiple-"][checkbox name="varPeachford" memo="Peachford" value=""] [conditional field=" varPeachford" condition="(varPeachford).is('')"][text size=65 default=" admission to Peachford "][/conditional][checkbox name="varRidgeview" memo="Ridgeview" value=""] [conditional field="vaRidgeview" condition="(varRidgeview).is('')"][text size=65 default="admission to Ridgeview "][/conditional][checkbox name="varGeorgia Regional" memo="Georgia Regional" value=""] [conditional field="varGeorgia Regional" condition="(varGeorgia Regional).is('')"][text size=65 default="admission to Georgia Regional "][/conditional][checkbox name="varLaurelwood" memo="Laurelwood" value=""] [conditional field="varLaurelwood" condition="(varLaurelwood).is('')"][text size=65 default="admission to Laurelwood "]

Family Medical History[checklist name="variable_1" value="Asthma|Cancer, NOS|Heart disease|Diabetes|Hypertension|Seizure disorder|Thyroid disease|Substance misuse|Dementia"]

Family Psychiatric History:[checkbox name="variable_29" value="Denies|None reported|Adopted, family history unknown|No known history|Unable to obtain due to patient's current presentation, none per review of chart and collateral hx"][checkbox name="variable_1" value="Completed suicide"]by
[text name="variable_1" default="sample text"] at age
[text name="variable_1" default="sample text"][checkbox name="variable_3" value="Suicide attempt"][checkbox name="variable_5" value="Depression"] [checkbox name="variable_7" value="Anxiety"][checkbox name="variable_9" value="Bipolar"][checkbox name="variable_11" value="Schizophrenia"][checkbox name="variable_21" value="Psychosis"][checkbox name="variable_23" value="PTSD"][checkbox name="variable_25" value="ADHD"][checkbox name="variable_13" value="Alcohol abuse"][checkbox name="variable_15" value="Substance abuse"][text name="variable_16" default=""] [checkbox name="variable_17" value="Psychiatric hospitalization"]
[checkbox name="variable_1" value="ECT treatments"][checkbox name="variable_19" value="Dementia"][text name="variable_20" default=""] [checkbox name="variable_27" value="Mental health problems, unknown/unclear type"]

Family History
[checklist name="variable_1" value="option Parents married|divorced|patient prefers not to answer"]
Mother
[text] Age
[select name="Q18" value="Alive|Deceased"]Passed away from
[text name="variable_1" default="sample text"]
Father
[text] Age
[select name="Q19" value="Alive|Deceased"]. Passed away from
[textarea name="variable_1" default="sample text"]
[text] # Siblings born
Patient is [text default="youngest, oldest, middle, etc."]
Family history of alcoholism
[select name="Q20" value="Father|Mother|Both parents"]

SOCIAL HISTORY:
Current Family and Significant Relationships
[checklist name="Q22" value="Living environment secure and supportive|Lack of social support from family|Lack of social support from friends|Lack of companionship|Interpersonal problems|Family problems|Family problems - Disruption|Family problems - Estrangement|Family problems - Physically or sexually abused by family member|ETOH use affecting relationships with others|Drug use affecting personal relationships"]
[text]
Relationship status: [text] # Total number of marriages
[checklist name="Q26" value="Separated"]
[checklist name="Q27" value="Divorced"]
[text] # Divorced times
[checklist name="Q28" value="Recently divorced"]
[checklist name="Q29" value="Widowed"]
[checklist name="Q30" value="Annulment"]
[text] [select value="|not currently in relationship|; currently in relationship|for
[text name="variable_1" default="sample text"] years to current spouse|since
[text name="variable_1" default="sample text"]after
[text name="variable_1" default="sample text"]years of marriage"]
Children: [select value="none|1|2|3|4|5|6|7|"] [checkbox value="adult children|sons|son|daughters|daughter"][checkbox value="- living|"][checkbox value=", 1|, 2|, 3|, 4|, 5|, 6|, 7|"] [checkbox value="sons|son|daughters|daughter|children|child|"] [checkbox value="step-children|close with whom with step-children|not close with step-children"]
Social History Continued
[checklist name="Q23" value="Living independently with spouse|Living with parents|Living with significant other"]
Spouse
[text] Age
Living situation:
[checklist name="variable_1" value="residence
[checkbox name="variable_1" value="home|apartment|trailer|homeless camp|shelter"][checkbox name="" value="|group home|memory care unit|skilled nursing facility|homeless, most recently|assisted living facility|nursing home|apartment in senior housing|dormitory"][select value="|staying with friends/family|staying at Mission|sleeping on streets|in homeless encampment|staying at hotel|, lives with spouse/significant other|, lives alone|, lives with roommates|, lives with family|, lives with parents|, lives with "][textarea rows="1"].
Life circumstance event
[checklist name="Q32" value="Physically abused"]
[checklist name="Q33" value="Sexually abused"]
[checklist name="Q34" value="Abused as child"]
[checklist name="Q35" value="Verbally berated, harassed, intimidated"]
[checklist name="Q36" value="Neglected as child "]
[checklist name="Q37" value="Abuse/neglect"]
[text]

Social Supports:
[checklist name="variable_1" value="none|spouse/significant other|extended family|adult children|neighbors|friends|church members|hired caregivers|limited support system|limited local supports|limited positive supports"]
Education: [select value="0|1|2|3|4|5|6|7|8|9|10
|11|12|12+"] years of formal education, [checkbox value="dropped out before finishing, no GED|high school diploma|GED|undergraduate degree|master's degree|vocational training|some college|vocational degree/certification|doctorate|currently in school"]
Employment: [checkbox value="retired|currently unemployed|not looking for work|looking for work|in process of applying for disability|disabled due to psychiatric illness|disabled due to medical problems|homemaker|currently employed|on maternity leave|on medical leave of absence"].
Field/Occupation: [textarea rows="1"].
Source of Income: [checkbox value="none|unclear/unknown|disability|social security|unemployment|work|savings|retirement|family support|inheritance|living off of settlement"][textarea rows="1"].
Military: [checkbox value="no reported history|denies history|retired|active|Army|Navy|Air Force|Marines|National Guard"]
[checkbox name="variable_1" value="honorably discharged|dishonorably discharged"]
Legal History: active issues- [checkbox value="none reported|denies|reports active legal issues related to |currently on probation[checkbox value="none reported| denies| previously incarcerated| past felony conviction|past history of violent offenses|denies past history of violent offenses|denies history of sex crimes|convicted sex offender|assault charges|protective orders|DFAC's involvement|Elderly abuse|probation"].

Specialty Physical Exam: Psychiatry
General Appearance:
[checklist name="variable_1" value="well developed|chachexia|clean|disheveled|unkept| malodorous|alert|cooperative|uncooperative|in no acute distress"]
HEAD: [checklist name="variable_1" value="normocephalic|other"]
EYES:[checklist name="variable_1" value="EOMI|vision intact|drainage|nystagmus|sclera|wears glasses
[select name="variable_1" value="has them with them|does not have them with them"]
THROAT: Oral cavity and pharynx normal. Teeth and gingiva in [checkbox name="variable_1" value="poor|good|dental carries|missing teeth|dentures|periorbital movements|"]
NECK: [checklist name="variable_1" value="normal range of motion|stiffness"]
CARDIAC: There is no peripheral edema, cyanosis or
pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds"
LUNGS: [checkbox name="variable_1" value="No shortness of breath, nonlabored|shortness of breath"]
ABDOMEN: No nausea or vomiting, last bowel movement[text name="variable_1" default="sample text"]"
MUSCULOSKELETAL: [checklist name="variable_1" value="option moves all extremities well|no spacticity|no atrophy noted"]
SKIN:[checklist name="variable_1" value="normal color|pallor|jaundice|skin turgor WNL|no lesions|lesions|rash|IV track marks|erythemia|rash|scarring from self injury
[textarea name="variable_1" default="sample text"]"]
NEUROLOGICAL:
[checkbox name="variable_1" value="patient refused to cooperate|unable to review"] due to
[text name="variable_1" default="sample text"]
[checklist name="variable_1" value="history of seizures|headaches|numbness/tingling"]
Gait: [select name="variable_1" value="choice Steady|choice Unsteady|choice Unable to ambulate at this time"]
CN I: Not tested
CN II: No abnormalities of pupil reactivity noted
CN III, IV, VI: Extraocular movements appear intact
CN V: No facial sensory asymmetry noted
CN VII: No facial droop noted
CN VIII: Hearing appears intact
CN IX, X: No asymmetry of palatal movements noted, no gag reflex abnormalities noted
CN XI: Shoulder shrug without any noted abnormalities
CN XII: Tongue protrusion without any noted abnormalities


Constitutional:
VS, weight

General Appearance - [select name="variable_3" value="well kept|poorly kept|appropriately dressed|inappropriately dressed|appropriately groomed|inappropriately groomed"].

Psychiatry ~
Psychomotor activity:
[checklist name="variable_1" value="option gait abnormalities|purposeless|repetitive|unusual postures|movements|tremors|dyskinesias| akathisia| mannerisms| tics| stereotypies| catatonic posturing| echopraxia| apparent responses to hallucinations)"]
Eye Contact: [select name="variable_7" value="eye contact good|eye contact fair|eye contact avoidant"]
Attitude:[checklist name="Q57" value="Distractible|Indifferent|Guarded|Defensive|Evasive|Bitter|Uninhibited|Ingratiating|Seductive|Inattentive|Disinterested|Uncooperative|Hostile|Full ranging|Indifferent (la belle indifference)|Blunted|Restricted|Angered"]
[text]
Speech:[checklist name="Q48" value="Normal Speech|Abnormal Rate - Slow|Abnormal Rate - Rapid|Abnormal Rate - Pressured|Abnormal Rhythm|Abnormal Tone|rapid|poetic|simplistic|rhyming|clanging"]
[text]
Thought Process:[checklist name="variable_1" value="linear|goal directed|disorganized|thought blocking|loosening of associations|tangential|derailment of thought|or knight's move thinking|persecutory|grandiose|circumstantial|poverty of thought|thought preservation|delusions of guilt|obsessions|over valued ideas"]
Mood:[checklist name="Q53" value="Normal|Angry|Anxious|Calm|Concerned|Depressed|Despairing|Dysphoric|Elevated|Empty|Euphoric|Expansive|Fearful|Frustrated|Futile|Guilty|Happy|Inappropriate|In Pain|Irritable|Joyous|Lability|Pleased|Unhappy|Self-contempt"]
Affect:[checklist name="variable_1" value="option congruent with mood|option incongruent with mood"][checklist name="Q56" value="Affect Congruent with mood
Abnormal Psychotic Thoughts/Perception (Hallucinations)
[checklist name="variable_1" value="denies Auditory hallucinations|denies visual hallucinations|Auditory hallucinations present
[checkbox name="variable_1" value="First person auditory illusions|second person auditory hallucinations|third party hallucinations"]|visual hallucinations|somatic hallucinations|visceral hallucinations|olfactory|gustatory hallucination|Delusions present|Paranoia present|paranoia denied| appears to be responding to internal stimuli"]
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"]
Intellect:Mental Functioning
[checklist name="Q50" value="Developmental|Impaired Calculation Ability|Abnormal Immediate Recall|Impaired Memory Remote|Low Fund of Knowledge|Cognitive|Unable to spell WORLD backwards"]
Insight: [select name="variable_18" value="normal|poor|fair|impaired"]
Judgment: [select name="variable_18" value="normal|poor|fair|impaired"]

COMPLETE MENTAL STATUS EXAM:
Orientation [checklist name="Q41" value="Oriented to Time, Place, Person"]
Memory:[checklist name="variable_1" value="option short term intact|option long term intact|option impaired short term|impaired long term|unable to assess"]
Attention: [select name="variable_13" value="no difficulty with attention or concentration|had some attentional and concentration problems during the exam"].Functions|Decreased|Perceptual disturbances visual"]
Language: Impairment|Verbal Impairment|Procedural Impairment"]
Abstraction: [select name="variable_17" value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"]Abstraction: no gross deficits noted
General Fund of knowledge: Mood/Affect - stated: [select name="variable_8" value="normal|upbeat|euthymic|depressed"].
Mood:[checklist name="variable_1" value="depressed|elated, anxious|guilty, frightened|angry|euthymic"]
Affect: - congruence: [select name="variable_11" value="mood is congruent with affect|mood and affect are not congruent"].
Cognition/Memory: [select name="variable_16" value="normal|grossly intact|below average|above average"].

# Serial Sevens [text]
[checklist name="Q44" value="Recall"]
[checklist name="Q45" value="Language"]
[checklist name="Q46" value="Copying a Design"]
[text]
Testing scores
[text] PHQ score [link url="https://www.soapnote.org/mental-health/patient-health-questionnaire-phq-9-calculator/" memo="calculator"]
[text] GAD 7 score [link url="https://www.soapnote.org/mental-health/generalized-anxiety-disorder-gad-7/" memo="calculator"]
[text] CAGE-AID score [link url="https://www.soapnote.org/mental-health/cage-aid/" memo="calculator"]
[text] ZUNG score [link url="https://www.soapnote.org/mental-health/zung-depression-scale/" memo="calculator"]
[text] AD8 Dementia Screening [link url="https://www.alz.org/documents_custom/ad8.pdf" memo="paper form"]

MDM:

#1 NEW:
A:
RISK: Such an acute change in psychiatric status indicates the patient requires inpatient psychiatric stabilization.
PLAN

#2 NEW:
A:
PLAN

#3 NEW:
A:
PLAN

#4 NEW: Tobacco Use Disorder
A: Patient is a chronic everyday smoker
PLAN
Nicotine Patch
tobacco counseling
monitor cravings
History and Physical
Laurelwood

Name:

DOB:

CSN:
MRN:
Date:

Chief Complaint:


HPI:

The patient is a
year old
with a past medical history of
.

Past psychiatric disorder patient reports:

Patient presented via
Patient presented with

due to
signed by
for
.

Patient is a
. At this time, the patient
suicidal ideations, homicidal ideations, auditory hallucinations and visual hallucinations. Lastly, patient denies elevated mood or euphoria that would be a concern for mania.

Historian:

Quality:

Severity: severe
Timing:
years|
"]days


Context: Scenerio in which symptoms began,
Modifying factors:

Associated signs and symptoms:


Treatment Planning:

Patients strengths:
Patient weaknesses:

Treatment Team:***

Progress towards goals:***

Recommended treatment:***

Psychiatric and Medical Review of symptoms~
General/Constitutional:
Psychiatric: Reports
Depression: .
Mania:

HEENT:
Pulmonary:
Cardio: Patient Patient reports
GI: Patient
Endocrine: Patient
Musculoskeletal:
Skin:
Patient reports

Neurologic:
Patient reports

Substance Abuse History:
|Heroin
|Prescription Pain medication
|Stimulants
|Hallucinogens
|option Cocaine


|Tobacco
|Caffeine
"]

Tobacco Use Treatment on Admission:
The healthcare provider offered tobacco use cessation on admission and it was received.

Past Psychiatric History:
Previous psychiatric care:Past Outpatient Tx: Psychiatric provider for medication Psychotherapy/Counseling Community Mental Health Center Mental Health Case Management
Previous psychiatric medications include:

Previous psychiatric diagnosis:
Previous suicidal ideations:

Suicide Attempts:
Non-Suicidal Self Injurious Behx:
Hx of Violence/Assaultive Behx:
Abuse/Trauma:
Violence:

Trauma History: .

Prior Treatment or Therapy inpatient/outpatient:
Past Inpatient Tx: Peachford Ridgeview Georgia Regional Laurelwood

Family Medical History

Family Psychiatric History: by
at age



Family History

Mother
Age
Passed away from

Father
Age
. Passed away from

# Siblings born
Patient is
Family history of alcoholism


SOCIAL HISTORY:
Current Family and Significant Relationships


Relationship status: # Total number of marriages


# Divorced times



years to current spouse|since
after
years of marriage"]
Children:
Social History Continued

Spouse
Age
Living situation:
.
Life circumstance event








Social Supports:

Education: years of formal education,
Employment: .
Field/Occupation:.
Source of Income: .
Military:

Legal History: active issues- .

Specialty Physical Exam: Psychiatry
General Appearance:

HEAD:
EYES:
THROAT: Oral cavity and pharynx normal. Teeth and gingiva in
NECK:
CARDIAC: There is no peripheral edema, cyanosis or
pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds"
LUNGS:
ABDOMEN: No nausea or vomiting, last bowel movement"
MUSCULOSKELETAL:
SKIN: "]
NEUROLOGICAL:
due to


Gait:
CN I: Not tested
CN II: No abnormalities of pupil reactivity noted
CN III, IV, VI: Extraocular movements appear intact
CN V: No facial sensory asymmetry noted
CN VII: No facial droop noted
CN VIII: Hearing appears intact
CN IX, X: No asymmetry of palatal movements noted, no gag reflex abnormalities noted
CN XI: Shoulder shrug without any noted abnormalities
CN XII: Tongue protrusion without any noted abnormalities


Constitutional:
VS, weight

General Appearance - .

Psychiatry ~
Psychomotor activity:

Eye Contact:
Attitude:

Speech:

Thought Process:
Mood:
Affect: |visual hallucinations|somatic hallucinations|visceral hallucinations|olfactory|gustatory hallucination|Delusions present|Paranoia present|paranoia denied| appears to be responding to internal stimuli"]
Thought form and content:
Intellect:Mental Functioning

Insight:
Judgment:

COMPLETE MENTAL STATUS EXAM:
Orientation
Memory:
Attention: .Functions|Decreased|Perceptual disturbances visual"]
Language: Impairment|Verbal Impairment|Procedural Impairment"]
Abstraction: Abstraction: no gross deficits noted
General Fund of knowledge: Mood/Affect - stated: .
Mood:
Affect: - congruence: .
Cognition/Memory: .

# Serial Sevens




Testing scores
PHQ score calculator
GAD 7 score calculator
CAGE-AID score calculator
ZUNG score calculator
AD8 Dementia Screening paper form

MDM:

#1 NEW:
A:
RISK: Such an acute change in psychiatric status indicates the patient requires inpatient psychiatric stabilization.
PLAN

#2 NEW:
A:
PLAN

#3 NEW:
A:
PLAN

#4 NEW: Tobacco Use Disorder
A: Patient is a chronic everyday smoker
PLAN
Nicotine Patch
tobacco counseling
monitor cravings

Result - Copy and paste this output:

Questions/General site feedback

One response to “work h & P”

  1. Mark Morgan says:

    Hi – I went through the first 100 lines and found a few errors which were causing it to crash. Below are the first 100 lines with my edits. Sincerely, Mark Morgan.

    History and Physical
    Laurelwood

    Name:
    [text name="variable_1" default="sample text"]
    DOB:
    [text name="variable_1" default="sample text"]
    CSN:
    MRN:
    Date:

    Chief Complaint:
    [textarea name="variable_1" default="sample text"]

    HPI:

    The patient is a
    [textarea name="variable_1" default="sample text"] year old
    [checklist name="variable_1" value="male|female|transgender|male identifying as female|female identifying as male|binary"] with a past medical history of
    [checklist name="variable_1" value="Abortion|Alcoholism|Anemia|Arthritis|Asthma|Brain Injury|Cancer, NOS|Chronic Pain|Constipation|COPD|Crohn's Disease|Dental Disorders|Dizziness|Diabetes Mellitus|Drug Dependence|Emphysema|Epilepsy|Fatigue|Fibromyalgia|Hepatitis|Hypertension|HIV Infection|Irritable Bowel Syndrome|Motor Neuron Disease|Obesity|Renal Disease|Sleep Disorder|STD|Stroke/CVA|Tuberculosis|Thyroid Disorders"].

    Past psychiatric disorder patient reports:[checkbox value="None|Depression|Anxiety|ADHD|OCD|PTSD|Oppositional Defiant Disorder|Autism Spectrum Disorder|Bipolar Disorder I|Bipolar Disorder II|Schizophrenia|Schizoaffective disorder|Borderline Personality Disorder|Antisocial Personality Disorder|Mood Disorder|Anxiety"]

    Patient presented via
    [checklist name="variable_1" value="private vehicle|EMS"] Patient presented with
    [checklist name="variable_1" value="option family|option friend|sheriff's department"]
    due to
    [checklist name="variable_1" value="arrest|by 2 part avadavit"]signed by
    [textarea name="variable_1" default="sample text"] for
    [textarea name="variable_1" default="sample text"].

    Patient is a
    [select name="variable_1" value="good historian|poor historian"]. At this time, the patient
    [select name="variable_1" value="denies|reports"] suicidal ideations, homicidal ideations, auditory hallucinations and visual hallucinations. Lastly, patient denies elevated mood or euphoria that would be a concern for mania.

    Historian:
    [textarea name="variable_1" default="sample text"]
    Quality:
    [checklist name="variable_1" value="depressed mood|anxious mood"]
    Severity: severe
    Timing:
    [checklist name="variable_1" value="new onset"]
    [text name="variable_1" default="sample text"]years|
    [text name="variable_1" default="sample text"]days
    [textarea name="variable_1" default="sample text"]
    [checkbox name="variable_1" value="constantly|intermittently"]
    Duration:
    [text name="variable_1" default="sample text"]
    Context: Scenerio in which symptoms began,[checklist name="variable_1" value="substances| medication noncompliance|other"]
    Modifying factors:
    [checklist name="variable_1" value="nicotine reduction|medication compliance|working with behavioral therapy|safety of housing|community resources|other"]
    Associated signs and symptoms:
    [checklist name="variable_1" value="mood liability|impulsivity|suicidality"]
    [checklist name="variable_1" value="anxiety|difficulty concentrating|irritability|anhedonia|social withdrawal and isolation|crying spells|sleep disturbance|sad mood"]

    Treatment Planning:

    Patients strengths: [checklist name="variable_1" value="willingness to seak treatment |motivation for treatment/growth|strong support system"]
    Patient weaknesses: [checklist name="variable_1" value="homelessness|Lack of financial means|lack of psychosocial support|substance use|lack of motivation for treatment|option low self esteem"]

    Treatment Team:***

    Progress towards goals:***

    Recommended treatment:***

    Psychiatric and Medical Review of symptoms~
    General/Constitutional:
    [checklist name="variable_1" value="reports weight gain|reports weight loss|changes in appetite| fatigue"]Psychiatric: Reports[select value="Denies any hallucinations or delusions.|"][select value="Denies past history of psychotic sx.|Endorses past history of psychotic sx.| Endorses past history of psychotic sx in context of substance abuse.|No clear history of psychosis in the absence of co-occurring substance abuse."]
    Depression: [select name="DepROS1” value="Denies any current depressive symptoms|Reports current depressive symptom of"] [checkbox name="depsx” value="sad mood|dysphoric mood|irritability|anhedonia|social withdrawal and isolation|crying spells|sleep disturbance|difficulty falling asleep, w/ delayed onset of sleep up to 1 hour|difficulty falling asleep, w/ delayed onset of sleep of 1 - 2 hours|difficulty falling asleep, w/ delayed onset of sleep greater than 2 hours|middle of night awakening|early morning awakening|moving or speaking so slowly that other people could have noticed|daytime fatigue|loss Of appetite|increased appetite|difficulty concentrating|decreased attention|increased anxiety|ruminative thoughts|feelings of worthlessness|excessive guilt|thoughts of death|mood symptoms are persistent and pervasive, varying little from day to day|depressed mood/sadness most of the time for 2-years or longer "]. [select value="Denies past history of depressive episodes.|Reports past history of depressive episodes."]
    Mania: [select name="ManROS1” value="Denies any current manic symptoms.|Reports current manic symptoms of"] [checkbox name="mansx" value="distinct period of abnormally and persistently elevated, expansive or irritable mood|accompanied by persistently increased goal-directed activity or energy|mood disturbance and increased energy/activity has lasted at least one-week and is present most of the day, nearly every day|mood disturbance and increased energy/activity has lasted at least 4 consecutive days and is present most of the day|pressured speech|inflated self-esteem|grandiosity|decreased need for sleep|hyperverbosity|flight of Ideas|subjective racing thoughts|distractiblity|psychomotor agitation|high risk activities"][checkbox value=". Denies behaviors occurred solely in the context of substance abuse.| Reports majority of sx occurred in the context of substance abuse."][select value="Denies past history of manic/hypomanic episodes.|Endorses past history of manic/hypomanic episodes.| Endorses past history of manic/hypomanic episodes in context of substance abuse. No clear history of past manic/hypomanic episodes in the absence of co-occurring substance abuse."]
    [textarea name="variable_3" default=""]
    HEENT: [checklist name="variable_1" value="dry mouth|involuntary oralfacial movements|headaches|light headedness|nasal congestion|blurred vision|vision changes|sore throat|loss of taste"]
    Pulmonary:[checklist name="variable_1" value="shortness of breath|dyspnea on exertion|cough"]
    Cardio: Patient [checklist name="variable_1" value=" neither reports or denies chest pain, palpitations, leg swelling"] Patient reports[checklist name="variable_1" value="chest pain|palpitations|leg swelling"]
    GI: Patient [checklist name="variable_1" value="neither reports or denies, abdominal pain, diarrhea, constipation, changes in stool, nausea or vomiting|Patient reports|abdominal pain|constipation|diarrhea|changes in stool|weight loss|nausea|vomiting"]
    Endocrine: Patient [checklist name="variable_1" value="neither confirms or denies, cold intolerance, polyuria, polydipsia|patient reports|cold intolerance|polydipsia|polyuria|dry skin|hair loss"]
    Musculoskeletal: [checklist name="variable_1" value="Patient neither confirms or denies joint pain, swelling, arthralgias, or back pain or weakness|Patient reports| back pain|joint pain|swelling, arthralgias|option weakness|option muscle pain"]
    Skin:[checklist name="variable_1" value=" Patient neither confirms or denies changes in skin, pruritus, rash or lesions"]
    [checkbox name="variable_1" value="scarring|no scarring"]Patient reports
    [checklist name="variable_1" value="pruritis|rash|lesions"]
    Neurologic:
    [checklist name="variable_1" value="Patient neither confirms or denies light headedness, fainting, seizures, headache, changes in gait or numbness|hx of black outs"]Patient reports [checklist name="variable_1" value="headaches|light headedness|seizures|weakness|numbness|gait changes|hx of black outs"]

    Substance Abuse History:
    [checklist name="variable_1" value="Patient neither confirms or denies any misuse of subtance's"][checklist name="variable_1" value=" None|Cannabis"]
    [textarea name="variable_1" default="sample text"]|Heroin
    [textarea name="variable_1" default="sample text"]|Prescription Pain medication
    [textarea name="variable_1" default="sample text"]|Stimulants
    [textarea name="variable_1" default="sample text"]|Hallucinogens
    [textarea name="variable_1" default="sample text"]|option Cocaine
    [text name="variable_1" default="sample text"]
    [checkbox name="variable_1" value="option Alcohol"]
    [textarea name="variable_1" default="sample text"]|Tobacco
    [textarea name="variable_1" default="sample text"]|Caffeine
    [textarea name="variable_1" default="sample text"]

    Tobacco Use Treatment on Admission:
    The healthcare provider offered tobacco use cessation on admission and it was received.

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