rachelnigloschy

Reason for visit/Chief Complaint:
Daily monitoring during detox per protocol

SUBJECTIVE:
[select name="variable_lastnamepronoun" value="Mr.|Ms.|Mx."] [text name="variable_ptname" default=""] continues    on     [checkbox name="sud" value="priamry    diazepam    taper|primary    lorazepam    taper|phenobarbital    taper|methadone    taper|buprenorphine    taper|"].
Exhibits    s/sx    of    withdrawls: [date name="variable_1" default=""] 
[checkbox memo="S/sx    of    withdrawals" name="If_detox1" value=""][conditional field="If_detox1" condition="(If_detox1).is('')"]: [checkbox name="continued" value="[checkbox name="sx" value="anxiety|agitation|tremors|diaphoresis|light    sensitivity|sound    sensitivity|proximal    sweats|tactile    disturbances|Administer meds assigned for symptomatic treatment associated with detox"]
[checkbox name="variable_23332" value="This patient is on taper day"] [text name="variable_tap" default=""]
[/conditional]
[checkbox memo="If opioids" name="If_detox2" value=""][conditional field="If_detox2" condition="(If_detox2).is('')"]Last Opioids (aproximately) [text name="variable_ops" default=""] [select name="variable_1time" value="hours ago|days ago"] of [select name="variable_op2" value="long-acting opioid|short-acting opioid"]
Protocol: [checkbox name="continued2" value="[checkbox name="detoxdrug" value="Suboxone induction|Suboxone maintenance|Gabapentin|Tegretol taper|Administer meds assigned for symptomatic treatment associated with detox"]
[/conditional]

Interval Medical History:
Patient    reports: [textarea name="variable_ciw" default=""]  
[checkbox name="medcc1" value="- This patient denies any current subjective complaints or acute medical concerns"]
[checkbox name="medcc2" value="- This patient denies any changes to current health status"]
[checkbox name="medcc3" value="- This patient denies any ADR or side effects to medications"]
[checkbox name="medcc5" value="- There have been no reported complaints by nursing staff"]
[checkbox name="medcc6" value="- This patient has been medication adherent"]
[checkbox name="medcc7" value="- This patient has not been medication adherent"]
[checkbox name="medcc9" value="- This patient endorses any side effects to medications"]
[checkbox name="medcc8" value="Updates on the progress of previously identified health issues include:"]
[checkbox name="medcc011" value="Changes in medication/treatment plan include:"][textarea name="concerns" default=""] 
[select name="variable_12427" value="|Safety: This patient is currently on a risk precaution for"] [checkbox name="variable_1" value="fall risk| seizure risk| suicide risk|self-harm risk|AMA risk"].[checkbox name="variable_riskfs" value="This patient has not had any incidences regarding this risk factor.|This patient has had any incidences regarding this risk factor"]

[checkbox name="variable_ac2" value="Acute Issues:"]
[textarea name="variable_2045" default=""]    
[comment memo="CO-MORBID CONDITION MONITORING UPDATES:"]
[checkbox name="variable_ccon" value="Chronic Issues:"][remark memo="Replace word NUMBER with numeral in field names chrNUMBER, controlNUMBER, symptomsNUMBER, currenttxNUMBER, prevtxNUMBER, ptxNUMBER1, ptxNUMBER2, ptxNUMBER3, medtxNUMBER, MedSideEffectsNUMBER, dxreqNUMBER, SatisfiedNUMBER, OtherSpecsNUMBER, and OtherDetailsNUMBER "]
[checkbox memo="#NUMBER" memo_size="small" name="chrNUMBER" value="-Chronic Condition-"][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"][comment memo="-------------BEGIN CONDITION NUMBER-------------"][comment memo_size="small" memo_color="blue" memo="select one ▼▼"][frontload soapnote="sample/drgfms-include-condition-dropdown/"]
- [textarea memo="◀︎◀︎ and/or freetext" memo_size="small" memo_color="blue" rows="2" cols="50"]
 - Patient reports that the condition is [select name="controlNUMBER" value="well controlled|not well controlled|stable|unchanged from last visit|improved from last visit|worse than at last visit"]
 - Currently, [select name="symptomsNUMBER" value="the patient notes there are no symptoms.|symptoms are present including"][/conditional][conditional field="symptomsNUMBER" condition="(symptomsNUMBER).is('symptoms are present including')"] [checkbox value="pain|fatigue|shortness of breath|palpitations|nausea|vomiting|abdominal pain|urinary symptoms"][text default="."]
[/conditional][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"][checkbox name="currenttxNUMBER" memo="current treatment" value=""][/conditional][conditional field="currenttxNUMBER" condition="(currenttxNUMBER).is('')"] 
 - Current treatments include [select name="medtxNUMBER" value="no medications.|medications including "][/conditional][conditional field="medtxNUMBER" condition="(medtxNUMBER).is('medications including ')"][textarea]. [select name="MedSideEffectsNUMBER" value="The patient denies side effects|The patient complains of side effects including "][/conditional][conditional field="MedSideEffectsNUMBER" condition="(MedSideEffectsNUMBER).is('The patient complains of side effects including ')"][checkbox value="|shortness of breath|dysnpea on exertion|orthostasis|diaphoresis|dizziness|drowsiness|vision changes|headache|dry mouth|sore throat|chest pain|palpitations|back pain|diahrrea|constipation|skin rash|insomnia|nausea|abdominal pain|vomitting|suicidal thoughts|anxiety|malaise"][textarea cols="50" rows="2" memo_size="small" memo_color="blue" memo="◀︎◀︎ include more here."][comment memo_size="small" memo_color="blue" memo=" Add a space/comma/period in front, as appropriate, if any above are selected"].[/conditional][conditional field="currenttxNUMBER" condition="(currenttxNUMBER).is('')"] [select name="othertxNUMBER" value="No other treatments are noted.|Additional treatments include "][/conditional][conditional field="othertxNUMBER" condition="(othertxNUMBER).is('Additional treatments include ')"][textarea cols="50" rows="2"]. 
[/conditional][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"][checkbox name="prevtxNUMBER" memo="previous treatments" value=""][/conditional][conditional field="prevtxNUMBER" condition="(prevtxNUMBER).is('')"]
[/conditional][conditional field="prevtxNUMBER" condition="(prevtxNUMBER).is('')"][checkbox name="ptxNUMBER2" value="  -#2 - "][/conditional][conditional field="ptxNUMBER2" condition="(ptxNUMBER2).is('  -#2 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][textarea memo="other reason" memo_size="small" memo_color="blue"]
[/conditional][conditional field="prevtxNUMBER" condition="(prevtxNUMBER).is('')"][checkbox name="ptxNUMBER3" value="  -#3 - "][/conditional][conditional field="ptxNUMBER3" condition="(ptxNUMBER3).is('  -#3 - ')"][text size="60"], reason discontinued - [checkbox value="intolerable side effects|no improvement"][textarea memo="other reason" memo_size="small" memo_color="blue"]
[/conditional][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"][checkbox memo="patient requests/needs diagnostic or lab tests" name="dxreqNUMBER" value=""][/conditional][conditional field="dxreqNUMBER" condition="(dxreqNUMBER).is('')"]
[textarea default=""][/conditional][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"][checkbox memo="Patient satisfied with treatment" name="PtSatisfied" value=""][/conditional][conditional field="PtSatisfied" condition="(PtSatisfied).is('')"]
- Pt [select name="SatisfiedNUMBER" value="|is|is not"] satisfied with current management[/conditional][conditional field="SatisfiedNUMBER" condition="(SatisfiedNUMBER).is('is not')"]; [text memo="details" size=60].[/conditional][conditional field="SatisfiedNUMBER" condition="(SatisfiedNUMBER).is('is')"].[/conditional][conditional field="chrNUMBER" condition="(chrNUMBER).is('-Chronic Condition-')"]
[comment memo="--------------END CONDITION NUMBER--------------"][/conditional]
Recovery Progress:  
- Depressive symptoms: Reported to be [select value="low|minimal|variable|manageable|medium|moderate|high|stable|present, but stable|present and unstable|unstable|stagnant|significantly better|somewhat better|somewhat worse|much worse|"]. [select value="||This could be attributed to|Current stability is attributed to|Current instability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to |"] [checkbox value="the continuation of current medications|the recent medication changes|dissatisfaction with medications|the positive response to medications|the lack of response to medications|situational stressors|situational stressors related to family|finanicial stressors|legal stressors|in-home stressors|in-facility stressors|home sickness|loneliness|grief|trauma|the adjustment to the environment|the incorporation of self-care|engaging with peers|engaging in individual therapy|engaging in group therapy|practicing coping skills|practicing TIPP skills|practicing STOP skills|practicing breathing excersise|the lack of application of coping skills|the lack of knowledge of coping skills|cravings for substances |abstaining from substance use|return to inpatient care|detox symptoms|post-acute withdrawal symptoms|decline in mental health|decline in physical health|improvement in mental health|improvement in physical health|changes in sleep patterns|lack of sleep|pain|upcoming discharge|discharge plan|unable to assess"]. [select name="variable_si" value="|Patient denies SI.| Patient endorses SI without plan or intent.| Patient endorses SI with plan.| Patient endorses self harming thoughts."]
- Anxiety symptoms: Reported to be [select value="low|minimal|variable|manageable|medium|moderate|high|stable|present, but stable|present and unstable|unstable|stagnant|significantly better|somewhat better|somewhat worse|much worse|"].  [select value="||This could be attributed to|Current stability is attributed to|Current instability is attributed to|Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | "] [checkbox value="the continuation of current medications|the recent medication changes|dissatisfaction with medications|the positive response to medications|the lack of response to medications|situational stressors|situational stressors related to family|finanicial stressors|legal stressors|in-home stressors|in-facility stressors|home sickness|loneliness|grief|trauma|the adjustment to the environment|the incorporation of self-care|engaging with peers|engaging in individual therapy|engaging in group therapy|practicing coping skills|practicing TIPP skills|practicing STOP skills|practicing breathing excersise|the lack of application of coping skills|the lack of knowledge of coping skills|cravings for substances |abstaining from substance use|return to inpatient care|detox symptoms|post-acute withdrawal symptoms|decline in mental health|decline in physical health|improvement in mental health|improvement in physical health|changes in sleep patterns|lack of sleep|pain|upcoming discharge|discharge plan|unable to assess"]. Anxiety is reported to be present [select value="occasionally.|mostly around situational stressors.|almost never.|about 50% of the time.|about 50-80% of the time.|most of the time on most days.|almost always.|"]
- Sleep is reported to be [select value="stable|unstable|stagnant|significantly better|somewhat better|somewhat worse|much worse|"]. [select value="|without any nightmares, interruptions, or dreams of substance use|This could be attributed to|Current stability is attributed to|Current instability is attributed to |Recent improvement is attributed to |Recent exacerbation is attributed to |Lack of improvement is attributed to | with difficulties falling asleep| with difficulties with frequent awakenings|with difficulties staying asleep|with difficulties with nightmares|with difficulties with oversleeping"] [checkbox value="the continuation of current medications|the recent medication changes|the lack of response to medications|the positive response to medications|anxiety|legal issues|situational stressors|detox symptoms|the adjustment in sleep environment|lifestyle improvements|engaging in individual therapy|pain|upcoming discharge|with sleep hygiene education"][textarea].
- Focus: [select name="variable_f123" value=" Patient reports adequate focus during groups|Patient reports adequate focus during groups and with peers|Patient reports poor attention and concentration in conversations with peers and staff| Patient reports poor attention and concentration in groups|Patient reports difficulty concentrating throughout the day|Patient reports poor attention and concentration in groups|Patient reports having difficulty with memory|Unable to assess|Unable to assess due to poor group attendance"].
- Cravings: [select name="variable_cr" value="cravings are moderate due to both external and internal triggers|cravings are minimal due to being in a protected environment and manageable with coping skills|cravings are minimal due to being in a protected environment and manageable with coping skills and MAT"]
- Appetite: [select name="variable_ap" value="denies any changes or concerns with appetite|reports poor appetite| nutritionally deficient|reports flucuation in appetite| reports eating disorder disturbance|reports eating greater than 50% of each meal| reports eating less than 50% of each meal| reports bulimic episodes AEB vomitting after eating|reports restricting diet|reports eating snack and meals daily"]____________________________________ 
___________________________________________ 
OBJECTIVE:
Withdrawal scores:[text name="variable_wds" default=" CIWA/ COWS"]; [select name="variable_trend" value="|trend is waxing and wanning|trend is stagnant| trend is improving| trend is worsening|trend is fluctuating"]

Physical examination:    
[VSS and patient asymptomatic]    
Constitutional: cooperative, [select name="variable_general" value="in no acute distress|intoxicated|fatigue| anxious appearing| restless| agitated| guarded"], [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| poor nutritional appearence| under-nourished| well-nourished"]   
Neuro: [select name="variable_neuro" value="A&O| A&Ox1|A&Ox2|A&Ox3|unable to determine|neurocognitive deficit seen| fatigue"]
Respiratory: lung sounds clear, no accessory muscle use    
Cardiac: RRR, no m/r/g, [select name="variable_edema" value="no edema|+1 edema|+2 edema| pitting edema present"]  
GI: abdomen soft, non-distended, non-tender. Bowel tones normoactive
Psych: [select name="variable_8" value="calm and cooperative||calm|normal|upbeat|euthymic|depressed|dysthmic|neutral|anxious|hostile|irritable|tearful"] 

ASSESSMENT/PLAN:
Impression: This patient was admitted due to an unstable pattern of substance use [checkbox name="variable_147" value="with concomitant inability to maintain sobriety independently"]. [select name="variable_time" value="Since admission|Over this last week|Over the last 24 hours|"], [select name="variable_howdo" value="this patient's clinical improvement is still in progress|this patient is pending clinical improvement||this patient's clinical improvement has been achieved|there has been minimal clinical improvement|there has been minimal clinical improvement due to resistence|this patient's clinical improvement has plateaued"]. Our team will continue to monitor and provide therpeutic intervention and medication management within a protected environment.

# Detoxification
[checkbox memo="Anticipated complications" name="bs" value=""]
[conditional field="bs" condition="(bs).is('')"][checkbox value="Anticipated complications include "][checkbox value="severe withdrawal symptoms|dehydration|malnutrition|electrolyte imbalance|sleep distruption|emotional distress|cardiovascular issues|post-acute withdrawal symptoms (PAWS)|risk of relapse|none identified"][/conditional] 
[checkbox memo="Current withdrawal complications" name="If_ETOH" value=""][conditional field="If_ETOH" condition="(If_ETOH).is('')"]Current complications include [checkbox name="variable_compl" value="none identified|severe withdrawal symptoms|dehydration|malnutrition|electrolyte imbalance|sleep distruption|emotional distress|cardiovascular issues|recent seizure activity|electrolyte imbalance|reported decrease renal function|acute kidney injury|liver disease|disorentation|persistent psychiatric illness|alcoholic hepatitis|transaminitis"][/conditional] 
[textarea name="variable_detox22" default="- Continue medication for withdrawal symptom management
- Monitor for s/s of withdrawal and CWS/CIWA scores
- Provide PRN medications as indicated for symptom management
- Educate on withdrawal process, detox protocol, medications
- Patient may attend outings at the discretion of the provider"]
[checkbox name="variable_155" value="- Revised nursing assessment frequencies"]

# Substance use treatment
Patient continues to reasonable benefit from admission in a protected environment to prevent relapse via medication management, education, skill building, and  therapeutic intervention. 
- Continue to monitor recovery in a protected environment 
- Encourage to engage in group sessions, individual therapy sessions, and outings per treatment plan  
- Coordinate treatment with the psychiatric team 
- Encourage engagement in ongoing relapse prevention and aftercare plan    
- [checkbox name="variable_MATinfo" value="SUD craving medication:"] [select name="variable_MATnow" value="|none|still deciding|declined all options|naltrexone PO| naltrexone PO with subsequent vivitrol injection on discharge|acamprosate|not applicable|gabapentin|topirmate|naltrexone PO and acamprosate|naltrexone with subsequent vivitrol injection on discharge and campral| previously completed naltrexone| previously completed acamprosate| previously completed vivitrol|suboxone|suboxone with subsequent sublocade injection"] 
* [checkbox name="variable_labsadmit" value="Pending admission lab results to assess overall health status and guide treatment plan"]
[checkbox memo="Admission Labs" name="labs" value=""][checkbox memo="MAT" name="mat" value=""]
[checkbox memo="Liver Conditions" name="If_liver" value=""][conditional field="If_liver" condition="(If_liver).is('')"]
# [select name="LD" value=" ||Elevated liver enzymes|Fatty liver disease| Liver disease| Alcoholic Hepatitis| Hepatitis C| Hepatitis B| Alcoholic Liver Disease| Cirrhosis| Pancreatitis|Viral Hepatitis|Liver cancer| Gallbladder disease"]
[checkbox name="LD" value="- No acute concerns note on follow up"][checkbox name="LDinfo" value="- Chronicity and stability established on admission, no further management needed at this time. Revisit plan of care if exacerbation occurs"][checkbox name="LDnoinf" value="- Pending lab findings to determine current health status and inform further management"]
[checkbox name="variable_125" value="- Acute findings include:"][text name="variable_1252" default=""]
[checkbox name="LDavoid" value="- Avoid drugs that cause hepatocellular injury and cholesteric abnormalities"][checkbox name="variable_folw" value="- Follow up with PCP upon discharge"][/conditional]
[checkbox memo="Hypertension" name="If_htn" value=""][conditional field="If_htn" condition="(If_htn).is('')"]# [select name="HTN" value=" |Hypertension|Elevated BP without a dx of HTN|Congestive heart failture| Heart disease"]
- Health status:
[select name="variable_stable" value="|-- stable BP, asymptomatic|-- unstable BP, asymptomatic|-- unstable BP, symptomatic|-- stable BP, symptomatic"]
- Monitoring:
[checkbox name="htnplannurse" value="-- Nursing to complete V/S checks as indicated by the provider or protocol"]
[checkbox name="htnplan" value="-- Patient is going through acute withdrawal from ETOH; pt blood pressures will be labile"]
- Medication:
[checkbox name="htnplancont" value="-- Continue MAR medications"][text name="variable_1" default=""]
[checkbox name="htnplanstart" value="-- Treatment adjustments:"][text name="variable_medst" default=""]
[checkbox name="htnplanmedno" value="-- Patient is not on medications"]
- Follow up:
[checkbox name="htnplanfu" value="-- Follow up with PCP upon discharge"][/conditional]
[checkbox memo="Diabetes" name="If_dm22" value=""][conditional field="If_dm22" condition="(If_dm22).is('')"]# [select name="DM" value=" |Type 2 diabetes mellitus without complications|Type 2 diabetes mellitus with hyperglycemia|Type 1 diabetes mellitus without complications|Type 1 diabetes mellitus with hyperglycemia|Other specified diabetes mellitus|Prediabetes"]
- Health status:
[checkbox name="dmplangoa1" value="-- BG WNL)"]
[checkbox name="dmplangoal" value="-- e/o hyperglycemia|-- e/o hypoglycemia episodes"]
[checkbox name="dmplannogo" value="-- Chronicity and stability established on admission"]
- Medication:
[checkbox name="dmplanmedno" value="-- Continue current medications"]
[checkbox name="dmplanmedn2o" value="-- Medications adjusted:"][textarea name="variable_1dm" default=""]
[checkbox name="dmplanmedno" value="-- Patient is not on medications"]
- Monitoring:
-- [select name="variable_1520z" value="|Monitor BG QIDAC+HS|Monitor BG BID|Monitor BG TID|Monitor BG QID|Monitor BG QD|Monitor BG Q Weekly"]
[checkbox name="variable_2202xs" value="-- Patient is electing not to monitor blood glucose"]
- Follow up:
[checkbox name="variable_103xcv" value="-- Follow up if exacerbation occurs"]
[checkbox name="dmplanfu" value="-- Patient should follow up with PCP after discharge"]
[/conditional]
[textarea name="medPOC" default=""]
[comment memo="COMMON STATEMENTS:
- no acute findings
- Pending lab findings to inform further management
- Pending lab findings to determine current health status
- Pending lab findings to determine current health status and inform further management
- Chronicity and stability established on admission, no further management needed at this time. Revisit plan of care if exacerbation occurs
-The patient's progress and medication needs will be continuously monitored and adjusted as necessary
- Follow up with PCP upon discharge"]

[checkbox memo="Suicide Risk" name="If_sic" value=""][conditional field="If_sic" condition="(If_sic).is('')"][select name="sxsicurrent" value="|# Suicidal ideation|# Recent suicide attempt|# Self-harm ideation|# Recent self-harm attempt"]
- continue suicide screenings qshift
- Monitor for any changes in the patient's mood, behavior, or suicidal ideation[/conditional]
[checkbox memo="Sleep Management" name="If_sep" value=""][conditional field="If_sep" condition="(If_sep).is('')"] [select name="variable_2024slep" value="# Sleep Management|# Insomnia"]
[checkbox name="variable_sep1" value="- Patient has declined sleep medications"]
[checkbox name="sleepad" value="- Treatment adjustments:"][text name="variable_med342" default=""][/conditional]
[conditional field="labs" condition="(labs).is('')"]
# ADMISSION LABS  
- see progress note for interpretation 
- see PHI for lab results
- labs reviewed with patient[/conditional]
[conditional field="mat" condition="(mat).is('')"]
[select name="variable_2223" value="# Medication-Assisted Treatment|# Cravings|choice C"]
The risk and benefits of this MAT medications have been explained to this patient. This patient has been provided education regarding this medication.
This patient would benefit from [checkbox name="variable_22" value="naltrexone|Vivitrol|acamprosate"].
[select name="variable_236" value="This patient declines MAT at this time| This patient accepts Naltrexone PO at this time|This patient accepts Naltrexone/ Vivitrol at this time| This patient is still deciding on MAT| This patient accepts acamprosate"] [/conditional]

Disposition: 
[select name="variable_202475" value="- Continue patient on detox status with 15 minute safety checks|- Transition patient to residential 1 status with 60 minute safety checks|- Transition patient to residential 1 status with 15 minute safety checks|- Transition patient to residential 2 status with 60 minute safety checks|- Transition patient to residential 2 status with 15 minute safety checks"]
- Continue collaborative care between the psychiatric and medical team.
- Upon discharge, the patient should maintain continuity of care with their primary care provider or establish care if one is not already in place. Any necessary specialist follow-ups should also be arranged