SUD/FNP H&P intake

Provider Name: Dr. Claire Baweja, DNP, APRN, FNP-C, CEN, SANE-A
Patient name: [text name="variable_ptname" default=""]
DOB: [text name="variable_2026" default=""]
Date of visit: [date name="variable_2025" default=""]
Time of visit: [text name="variable_time2" default=""][select name="variable_daytime" value="|AM|PM"]

CC: [comment memo="precipitating event"][text name="variable_cc" default=""]

HPI:
[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"], [select name="variable_pmhno" value="with a past medical history of|with no past medical history."] [textarea name="pmhhip" default=""]. This patient was voluntarily admitted to Northpoint Nebraska on [date name="variable_datead" default=" "] for [select name="variable_txneeds" value="medical detox treatment and subsequent recovery services| recovery services status post detox at another facility| recovery services"] in the context of [select name="variable_why" value="self-identified decompensation with the ongoing and excessive use of|relapse of|legal issues associated with the use of"]  [checkbox name="sud" value="alcohol|adderall|amphetamines|anxiolytics|ativan|benzodiazepines|cannabis|cannabis (synthetic)|codeine|cocaine|crack|fentanyl|hallucinogens|heroin|hypnotics|inhalants|ketamine|kratom|MDMA|opioids|oxycodone|other psychoactive substances|phenibut|methamphetamines|sedatives|stimulants|vyvanse|xanax"]
[textarea name="variable_pmhsud" default="This patient states their primary drug of choice is. He/She has been using  . Last use: .His/Her use of substances is associated with several life stressors including. No other co-occurring illicit substance use. Substance use history is unremarkable for previous short-term or long-term treatment, significant periods of sobriety; previous MAT (without any improvement in cravings), overdoses, previous complications related to withdrawal, or hospitalizations regarding substance use or withdrawal. Admission BAC  . On examination, he/she denies any current withdrawal symptoms or cravings at this time. This patient denies any SI today. "]
Patient denies acute pain or medical concerns. [select name="variable_1" value="VSS|VSS; asymptomatic  with hypertension|VSS;    asymptomatic with hypertension and tachycardia present on admission|VSS; asymptomatic with tachycardia"] and patient is not in acute distress.

Functional impairments caused by SUD: 
- Interpersonal functioning [text name="variable_2022" default=" "]
- Psychological functioning  [text name="variable_2023" default=" "]
- Inability to live without recurrent abuse of chemicals [text name="variable_2024" default=" "]

[checkbox memo="Current Psychiatric Status" name="If_da" value=""][conditional field="If_da" condition="(If_da).is('')"] 
Current Psychiatric Status:
Patient reports their depression is [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 [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"]. 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 [checkbox name="sleepprob" value="no difficulties|difficulties falling asleep| difficulties with frequent awakenings|difficulties staying asleep| difficulties with nightmares|restless legs|sleep apnea"].[comment memo="A fasting ferritin level of 75 ng/mL or less can cause restless leg syndrome. Ferritin is an acute phase reactant, so transferrin saturation (TSAT) less than 20% may be a more accurate measurement. Ideally an early morning, fasting iron panel including iron, TIBC, ferritin and TSAT should be drawn. (TSAT = iron ÷ TIBC × 100)"] Patient [select name="variable_si2" value="denies|endorses"] [select name="variable_si3" value="any current hallucinations, paranoia, suicidal ideation, or homicidal ideation.|passive suicidal ideation|suicidal and homicidal ideation| hallucinations| paranoia| hallucinations and paranoia| active suicidal ideation| active suicidal ideation without intent or plan| active suicidal ideation with plan and without intent| homicidal ideation| self-harm ideation without the intent to die|"][/conditional]
[checkbox memo="Symptomlogy on admission" name="psych_sym" value=""][conditional field="psych_sym" condition="(psych_sym).is('')"]
Symptomology on Admission:
- Presence of depressive symptoms: [select name="dephx" value="none|yes|yes, history"] [text name="dephx" default=""]
- Presence suicidal ideation or concerns to attempt: [select name="anxhx" value="none|yes|yes, history"] [text name="anxhx" default=""]
- Presence of auditory/ visual/ tactile hallucinations:  [select name="manhx" value="none|yes|yes, history"] [text name="mahx" default=""]
- Presence of paranoia: [select name="adhdhx" value="none|yes|yes, history"] [text name="adhdx" default=""]
- Presence of PTSD symptoms:  [select name="racehx" value="none|yes|yes, history"] [text name="racehx" default=""]
- Presence of manic symptoms (i.e. racing thoughts, distractible, grandiose, delusional, risky behavior, agitation): [select name="moodhx" value="none|yes|yes, history"] [text name="moodhx" default=""]
- Presence of mood swings [select name="hallhx" value="none|yes|yes, history"] [text name="hallhx" default=""]
- Presence or history of OCD: [select name="ocdhx" value="none|yes|yes, history"] [text name="ocdhx" default=""]
- Presence or history of eating disorder: [select name="eathx" value="none|yes|yes, history"] [text name="eathx" default=""][/conditional]
[checkbox memo="Substance Use History" name="If_sudhx" value=""][conditional field="If_sudhx" condition="(If_sudhx).is('')"]__________________
Substance Use History:
History of seizures? [select name="variable_szhsi" value="denies|confirms|unknown"]
History of IVDU? [select name="variable_ivdus" value="denies|confirms|unknown"]
[textarea name="variable_sud222" default="- See HPI and nursing intake for further information regarding pattern of use."][/conditional]
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PMH:
Allergies: [text name="variable_aller" default="NDKA"]
Medical conditions:  
[checkbox name="negpmh" value="Patient denies any significant past medical history or current concerns"]
[checkbox memo="Diabetes" name="If_dm" value=""][conditional field="If_dm" condition="(If_dm).is('')"] # Diabetes
- Diagnosed: [text default="yyyy"]
--- The patient is followed [select value="by a primary care physician|by the diabetes clinic|by primary care physician and diabetes clinic|by the family medicine team|other" name="provider"]
--- In the past year the patient has had the following diabetic visits: [select value="no|one|two|three|four|five|more than five|multiple"] visits in the hospital, [select value="no|one|two|three|four|five|more than five|multiple"] visits to the ER. 
- Diet: The patient [select value="is not following a diet|is on a carb counting diet|is following an optimal diet|is having difficulties following the diet|would like further education on their diet"].
- Monitoring: The patient performs monitoring of blood glucose [select value="once a day|twice a day|three times a day|four times a day|once a week|twice a week|three times a week|at no specific times|at clinic visits| with meals| before meals and snacks| before meals and snacks and at night"].
--- [select name="variable_dmdrop" value="|Patient uses a glucometer|Patient uses CGM|Patient uses CGM and insulin pump"]
- Medications: [text name="variable_1dm" default=""]

History of the following diabetes complications:
Diabetic ketoacidosis- [select value="NO|YES" name="DKA"] [conditional field="DKA" condition="(DKA).is('YES')"] [text default="diabetic ketoacidosis details" size=140][/conditional]
Hyperosmolar hyperglycemic state- [select value="NO|YES" name="HHS"] [conditional field="HHS" condition="(HHS).is('YES')"] [text default="hyperosmolar hyperglycemic state details" size=140][/conditional]
Hypoglycemia- [select value="NO|YES" name="hypoglycemia"]  [conditional field="hypoglycemia" condition="(hypoglycemia).is('YES')"] [text default="hypoglycemic episode details" size=140][/conditional]
Eye complications- [select value="NO|YES" name="eye"] [conditional field="eye" condition="(eye).is('YES')"] [text default="eye complication details" size=140][/conditional]
Nephropathy- [select value="NO|YES" name="kidney"] [conditional field="kidney" condition="(kidney).is('YES')"] [text default="nephropathy details" size=140][/conditional]
Neuropathy- [select value="NO|YES" name="neuro"] [conditional field="neuro" condition="(neuro).is('YES')"] [text default="neuropathy details" size=140][/conditional]
[/conditional]
[checkbox memo="Hypertension" name="If_htn2" value=""][conditional field="If_htn2" condition="(If_htn2).is('')"] [select name="variable_htnchoicess" value="# Hypertension|# Elevated blood pressure without diagnosis of hypertension|# Elevated blood pressure on admit"]
- BP on admit [text name="variable_htn23" default=""]
- Medications include: [text name="variable_htnmeds2" default=""]
- Patient reports that the condition is [select name="controlNUMBER" value="well controlled|not well controlled|stable|unstable|unaware|unchanged from last admit|improved from last admit|worse than at last admit"]
 -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=" chest pain|fatigue|shortness of breath|palpitations|headache|vision changes| headache|nausea|vomiting|abdominal pain|urinary symptoms"]
[/conditional]
[textarea name="pmhmed" default="  "]
Psychiatric history:
- Diagnosis: [checkbox name="variable_psychdx" value="none|Depression|MDD|Anxiety|GAD|PTSD|ADHD|ADD|OCD|Bipolar Disorder|Schizoaffective Disorder|Schizophrenia|Paranoia|Borderline Personality Disorder|Autism|Panic Disorder|Gambling Disorder|Other mood disorder"] [text name="psych_dx" default=""]
- [select name="variable_medspsych" value="Current meds:|Trialed Meds:|Current meds/Trialed Meds:"][text name="psych_medsdes" default="none"]
- History of psychiatric inpatient treatment: [text name="psych_tx" default="none"]
- History of SI/SA/SH: [select name="sihx" value="denies|endorses"] [text name="sihx" default=""]
- History of homicidal ideation or attempt: [select name="hihx" value="denies|endorses"] [text name="hihx" default=""]
- History of violence to others (in the last 6 months): [select name="vihx" value="denies|endorses"] [text name="vihx" default=""]
[checkbox memo="Psych History" name="psych_hx" value=""][conditional field="psych_hx" condition="(psych_hx).is('')"] [textarea name="variable_psychpmh" default=""][/conditional]

[checkbox memo="female only" name="If_female" value=""][conditional field="If_female" condition="(If_female).is('')"] OB/GYN HISTORY: 
LMP: [date name="3" default=""][checkbox name="variable_unknownlmp" value="unknown|irregular|irregular due to birth control"]
[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|ablation|oopherectomy"][/conditional]
__________________
PAST SURGICAL HISTORY:
[checkbox name="negsurg" value="Patient denies any significant surgical history "][textarea name="pastsurg" default=" "]  

PREVIOUS HOSPITALIZATIONS:
[checkbox name="neghosp" value="Patient denies any previous hospitalizations"][textarea name="pasthosp" default=" "]  
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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="|unknown|no|yes"]
[checkbox memo="Seasonal Influenza" name="If_flu" value=""][conditional field="If_flu" condition="(If_flu).is('')"] 
Influenza (seasonal): [select name="flu" value="|unknown|no|yes"]
(Would you like an influenza vaccination while in service? [select name="flunew" value="|unknown|no|yes"])
[/conditional]
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FHx:
[checkbox name="variable_fmhx" value="Patient denies any relevant medical, psych, or SUD history"]
[checkbox name="variable_fmhx5" value="Patient unable to recall any family medical history"]
[checkbox name="variable_fmhx1" value="Patient is adopted and is without knowledge of family history"]
[checkbox name="variable_fmhx2" value="Patient is adopted and is with knowledge of family history"]
[textarea name="variable_fmh" default=""]

SHx:
-Family Constellation: Patient has [select value="no|1|2|3|4|5|6|7|8|"] [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|lives with family|with children| lives with partner| lives with roommates| homeless| transient| shelter-based| residing with friends or family as short term guest| residential facility| nursing home| refugee| correctional facility| mobile home"]
- 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|"][text name="variable_work" default=""]
- Legal Issues: [textarea name="legal" default="Denies any current or past history of jail/prison, probation/parole, charges or pending charges."]
- Tobacco Use: [select name="variable_smk" value="endorses|denies|unable to answer"][text name="variable_nicotinehx" default=""]
- 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"].
- Diet: [select name="variable_diets" value="general|vegan|vegetarian|pescatarian|carnivore|gluten-sensitive|keto|shellfish allergy|ovo-lacto vegetarian"]
- Safety: [select name="variable_safetyh" value="No safety concerns reported|Concerns of domestic violence|Concerns of sexual assault|concerns of human trafficking|Concerns for childabuse in the household"]
__________________
ROS: 12-point system reviewed; Pertinent negatives and positives discussed in HPI.
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PE:
Vital signs reviewed.

General: A&O x3, [select name="variable_good" value="cooperative|uncooperative|"], [select name="variable_general" value="in no acute distress|intoxicated|fatigue|anxious appearing| restless|agitated|disheveled"], [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"]
Skin: No rash noted. [select name="variable_skin" value="Warm & dry|sweating|diaphoretic|redness|cyanotic"] with normal turgor. [select name="variable_jaundice" value="No jaundice noted.|Jaundice noted.|Skin mottled."] See body diagram 
Head: Head is NC/AT. Scalp is without lesions.
EENT: PERRLA, EOMI, pupils [select name="variable_pupil" value="3mm|4mm|2mm|5mm"], [select name="variable_eyes" value="sclera and conjunctiva without erythema or injection|conjunctival icterus present|subconjunctival hemorrhage present"]. 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: Full ROM. Trachea is midline. 
Pulmonary: Air entry normal. Breathing unlabored. Lungs CTA bilaterally without adventitious sounds.[select name="variable_resp2" value="|cough present on admit"]
CV: RRR w/ no appreciable m/r/g. No peripheral or generalized edema. +2 pulses in upper and lower extremities
GI: Soft, [select name="variable_ge" value="Nondistended|distended"]. No organomegaly or masses noted. [select name="variable_TTP" value="No rebound or guarding|TTP|pain located:"]. [select name="variable_ge2" value="No Hepatosplenomegaly|"]. [select name="ascites" value="No ascites|ascites appreciated"]. Bowel sounds present.
MSK: Bilateral upper/lower extremities: symmetric, adequate muscle tone with 5/5 muscle strength, full ROM. No CVA tenderness
Neuro:  CNs 2-12 grossly intact. Speech is [select name="variable_speech" value="normal|abnormal|slurred|pressured|stuttering"]. [select name="variable_gait" value="Normal gait|Abnormal gait|Abnormal gait due to intoxication| Abnormal gait due to medical assisted device| Normal gait with medical assisted device"]. UE and LE DTRs 2+ & equal B/L; No orthostasis.[select name="variable_tremors" value="|Tremors present."]
PSYCH/MSE:
--Behavior - general: [select name="variable_4" value="in no acute distress|in acute psychological distress"].
--Behavior - interactivity: [select name="variable_6" value="polite and cooperative|interactive|withdrawn|hostile|questioning|demanding|agitation present|guarding|limited engagement in conversation|fidgeting|dyskinesia|compulsion|retardation|tense|restless|impulsive|pacing|tremors|tics"].
--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|content|melancholy|detached|indifferent|anger"].
--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 process: [select name="variable_202" value="organized and understandable| understandable|word salad| disorganized|loose associations|tangential"], [select name="variable_12" value="normal|future oriented|incoherent|logical, linear and goal-oriented|past oriented and somber|goal directed|scattered|hopeful|remorseful|enthusiastic|resigned|tangential|circumstantial||"]
--Though Content: [select name="variable_17" value=" no evidence of delusions, paranoia, or preoccupations| no evidence of response to internal stimuli| preoccupied| paranoia present| delusions present| homicial ideation| suicidal ideation present| passive SI present "]
--Attention: [select name="variable_13" value=" adequate attention and concentration based on answers to interview questions|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| fair"]
--Perception- general: [select name="variable_24" 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|attention span limited|fund of knowledge present"].
--Judgment: [select name="variable_18" value="normal|poor|good|impulsive"].
--Risk: [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"].
__________________
DIAGNOSTICS:
Breathalyzer testing on admission -[text name="variable_BACs" default=""]
[link url="https://www.mdcalc.com/calc/10102/prediction-alcohol-withdrawal-severity-scale" memo="PAWSS"][checkbox name="variable_PAWSS" value="Prediction of Alcohol Withdrawal Severity Scale (PAWSS)"]- [text name="variable_PAWSSs" default=""][select name="variable_paws" value="|N/A|unable to score"]
[select name="variable_labsdoneor" value="- Labs collected on admission:|- Labs collected prior to admission-see chart|- Labs collected prior to admission-awaiting information|"]
[checkbox name="variable_actuallab" value="CBC, CMP, TSH w/ reflex, UA w/ reflex, Urine Drug Screen, Mg, HCV"] 
[checkbox name="variable_labsmore" value="Hgba1c|Lipid panel|Hepatits Panel|Coag studies(PT/PTT/INR)|STD Testing|Vaginitis Panel|HIV|RPR|HSV|Testosterone| CRP|Prolactin|FOCT|Microalbumin|COVID-19|Influenza A/B|Keppra level|Valproic Acid levels|Lipase/Amylase"]
[text name="labtest" default=""]
__________________
A&P
[checkbox memo="Problem List" name="If_ap" value=""][conditional field="If_ap" condition="(If_ap).is('')"][textarea name="variable_apa" default="Principle Problem: Alcohol Withdrawal
Active Problems:"][/conditional]
[checkbox memo="Disposition" name="If_dispo" value=""][conditional field="If_dispo" condition="(If_dispo).is('')"][textarea name="variable_dispo" default="Demographis,PMH,cc,how many admits"][/conditional]
Reason for Admission: This patient is here for voluntary admission for medically-managed withdrawal and recovery in a protected environment. Throughout the course of this admission, this patient will participate and benefit from a structured intervention program. This program is designed with a focus on educating the patient about the complexities of substance use, approaching it as a disease. This program will also provide therapy to address and enhance interpersonal effectiveness, coping mechanisms, and emotional regulation.
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ACTIVE PROBLEMS/MEDICAL PLAN:
[checkbox memo="Substance Use Withdrawal" name="If_no34" value=""][conditional field="If_no34" condition="(If_no34).is('')"]
# [checkbox name="sud32" value="alcohol withdrawal|amphetamine withdrawal|cannabis withdrawal|sedative, hypnotic, anxiolytic withdrawal|opioid use withdrawal|cocaine use withdrawal|other stimulant use withdrawal|hallucinogens use withdrawal|inhalant withdrawal|other psychoactive substances and multiple drug use withdrawal"] 
[checkbox memo="Anticipated complications" name="bs" value=""]
[conditional field="bs" condition="(bs).is('')"]Anticipated complications include [checkbox value="severe withdrawal symptoms|dehydration|malnutrition|electrolyte imbalance|sleep sleep disruption|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 sleep disruption|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"]
Admission BAC [text name="variable_bacad" default=""]. Last use: [text name="variable_usel" default=""][/conditional]. 
Detoxification:
Therapeutics:[checkbox name="continued" value="[checkbox name="detoxdrug" value=" Librum per protocol| Ativan per protocol|Suboxone per protocol| Valium per protocol| Ativan PRN per protocol| Gabapentin| Tegretol Taper| Administer meds assigned for symptomatic treatment associated with detox"]
[checkbox name="variable_elsewhere" value="No detox medications prescribed as patient completed detox at another facility"]
[checkbox memo="declines taper" name="If_notape" value=""][conditional field="If_notape" condition="(If_notape).is('')"]- The patient is aware that they meet criteria to start a taper; however, declines a scheduled  taper at this time. If CIWA continually elevated without relief from Ativan PRN, we will reconsider this approach. Patient is aware of risk and benefits of taper vs. symptomatic treatment.[/conditional]
[checkbox memo="If opioids" name="If_detox3" value=""][conditional field="If_detox3" condition="(If_detox3).is('')"]
[checkbox memo="Initiation" name="If_detox4" value=""][conditional field="If_detox4" condition="(If_detox4).is('')"]
MOUD Tx:
-- [checkbox name="variable_mouds3" value="Patient has met criteria to start MOUD|Patient has NOT met criteria to start MOUD"]
[checkbox memo="No Initiation" name="If_detox84" value=""][conditional field="If_detox84" condition="(If_detox84).is('')"]
-- [select name="variable_14752" value="Nursing to monitor CWS; if subsequent CWS after admission are >13; consider starting MOUD"][/conditional]
[checkbox memo="Initiation" name="If_detox74" value=""][conditional field="If_detox74" condition="(If_detox74).is('')"]
-- [select name="variable_14526732" value="Begin buprenorphine-naloxone induction with 2mg/0.5mg|Begin buprenorphine-naloxone induction 4mg/1mg "] every [text name="variable_hrs" default="4"] hours 
-- [checkbox name="variable_45" value="Plan for patient to use total dose of 12mg/3mg per day|Plan for patient to use total dose of 16mg/3mg per day"]
[checkbox name="variable_120" value="-- Given their prior dose of opioid use, may need higher
dose. Will follow closely"][/conditional]
[checkbox memo="Maintenance" name="If_detox5" value=""][conditional field="If_detox5" condition="(If_detox5).is('')"]
-- Continue buprenorphine-naloxone [text name="variable_bup" default="4mg/1mg TID"] for stabilization/maintenance phase of treatment
[/conditional]
[/conditional]
[/conditional]
[checkbox name="variable_mvi" value="-- Added Thiamine, Folate, and MVI"]
-- Monitor withdrawal symptoms and provide PRN medications as indicated
-- Educated on the withdrawal process, detox protocol, medication management, and side effects
Assessment:
-- Pending lab results to assess overall health status and guide treatment plan
[comment memo="Lab alternative"][checkbox name="variable_labsalt" value="-- Labs were available prior to arrival; reviewed by    provider"]
-- Defer to the psychiatric team for psychiatric intake
Monitoring
-- Continue to monitor overall health status during detox and subsequent recovery in a protected environment
Safety
[checkbox name="variable_safe" value="-- Fall risk precaution while   on detox only|-- Fall risk precaution|-- Seizure risk precautions"]
[/conditional]
# [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"] 
Monitoring:
-- Facility status: [select name="variable_202475" value="Detox with 15-minute safety checks|Residential 1 with 60-minute safety checks|- Residential 1 with 15-minute safety checks|Residential 2 with 60-minute safety checks|Residential 2 with 15-minute safety checks"]
-- Continue to monitor recovery in a protected environment
-- Continue psychiatric-medical team collaboration, and update interdisciplinary team
Medication:
--Comprehensive evaluation was completed to determine suitable medication-assisted treatment (MAT) based on the patient’s substance use and overall health. The risks and benefits of MAT medications have been explained to this patient. This patient has been provided education regarding this medication. [checkbox name="variable_1MAT2" value="Informational drug packet given to patient."] [select name="variable_mat23" value="-- This patient would benefit from |-- Discussed off label use of medications for cravings for SUD "][checkbox name="variable_22" value="naltrexone|vivitrol|acamprosate|disulfram|suboxone|topirmate|gabapentin"].
--[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 inititating MAT| This patient accepts acamprosate"]
Therapy:
-- Initiate individual and group therapy sessions for substance use disorder and encouraged maximal attendance
Aftercare  Planning:
-- Explore options for long-term sobriety support, including inpatient rehabilitation and sober living
--[checkbox memo="MMDR" name="If_mmdr" value=""][conditional field="If_mmdr" condition="(If_mmdr).is('')"] Medical Management of Discharge and Relapse: For the patient's health and safety, it is medically advised that any relapse of illicit substances should be promptly considered and evaluated for the appropriate level of care prior to readmission. This assessment is necessary to determine if there is a likelihood of benefit from short-term residential care or if a higher level of care is required due to suboptimal outcomes already received at an earlier time at this current care level.[/conditional]
[checkbox memo="MAT" name="mat" value=""]
[conditional field="mat" condition="(mat).is('')"]
[select name="variable_mat22" value="# Medication-Assisted Treatment|# Cravings for substances|"]
The risk and benefits of this MAT medications have been explained to this patient. This patient has been provided education regarding this medication. [checkbox name="variable_1MAT2" value="Informational drug packet given to patient."] [select name="variable_mat23" value="This patient would benefit from|Discussed off label use of medications for cravings for SUD"][checkbox name="variable_22" value="naltrexone|vivitrol|acamprosate|suboxone"].
[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]
[checkbox memo="FENGI" name="FENGI" value=""][conditional field="FENGI" condition="(FENGI).is('')"]# FEN/GI
--[checkbox name="variable_feng" value="Provide nutritional support with thiamine, folate, and multivitamin; encourage oral hydration and healthy eating to promote continual wellness"] 
[checkbox name="variable_add" value="**Patient is identified as at-risk for nutritional status**"]
[checkbox name="variable_multivit" value="- Daily multivitamin ordered"]
[checkbox name="variable_b12" value="- Folic Acid/Thiamine replacement ordered"]
[checkbox name="variable_diet" value="- Continue general diet as tolerated"]
[checkbox name="variable_add" value="- Ensure added to supplement meals"]
[checkbox name="variable_pro" value="- Recommended high protein diet"]
[checkbox name="variable_carb" value="- Recommended carb controlled diet"]
[checkbox name="variable_na" value="- Recommended low salt diet <2 grams"][/conditional]
[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="- Reported elevated liver enzymes by pt"][checkbox name="LDinfo" value="- Previous labs and information obtained regarding liver enzymes"][checkbox name="LDnoinf" value="- No current information regarding liver status"][checkbox name="LDrf" value="- R/F include AUD"][checkbox name="LDrfp" value="- R/F include PWID"][checkbox name="LDlabs" value="- Labs pending"][checkbox name="LDavoid" value="- Avoid drugs that cause hepatocellular injury and cholesteric abnormalities"][/conditional]
[checkbox memo=" Fib-4" name="If_fib" value=""][conditional field="If_fib" condition="(If_fib).is('')"]
- Fibrosis-4 (FIB-4) Calculator: [checkbox name="Fib4" value=" undertermined"]
[text size=3 name="age"] <-- Age
[text size=3 name="alt"] <-- ALT
[text size=3 name="ast"] <-- AST
[text size=3 name="plt"] <-- Platelets
[calc memo="number" value="score=((ast)*(age)/((plt)*(Math.pow((alt),0.5)))).toFixed(2)"] <-- score
[calc memo="number" value="score2=((ast)*(age)/((plt)*(Math.pow((alt),0.5)))).toFixed(2);score2>3.25?'possibly consistent with advanced fibrosis':score2>=1.45?'within the normal zone':'possibly consistent with advanced fibrosis'"] <-- interpretation (advanced fibrosis may be present above 3.25 and below 1.45)
[checkbox memo="Hide/Display References" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
references: 
 [link url="//pubmed.ncbi.nlm.nih.gov/16729309/" memo="#1"] Sterling RK, Lissen E, Clumeck N, et al. Development of a simple noninvasive index to predict significant fibrosis in patients with HIV/HCV coinfection. Hepatology. 2006;43(6):1317-1325.[/conditional][/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"]
Goals:
[checkbox name="htnplangoa1" value="- Goal BP is SBP<140, DBP<90 (if less than 65)/SBP<130, DBP<80 (if 65 or older or co-morbid conditions present)"]
[checkbox name="htnplangoal" value="- Patient is at goal"]
[checkbox name="htnplannogo" value="- Patient is not at goal"]
Monitoring:
[checkbox name="htnplan" value="- Patient is going through acute withdrawal from ETOH; pt blood pressures will be labile"]
[checkbox name="htnplannurse" value="- Nursing to complete V/S checks per protocol or as indicated by the provider"]
[checkbox name="htnplanlabs" value="- Pending labs to inform    further management"]
Lifestyle changes:
[checkbox name="htnplangoa2l" value="- Patient was educated about healthy diets, regular exercises, weight control, and reduction of sodium and alcohol intake. Advised quitting smoking if applicable"]
Medication:
[checkbox name="htnplanmedlike" value="- Patient is adherent to medications"]
[checkbox name="htnplannomed" value="- Patient is not adherent to medications"]
[checkbox name="htnplancont" value="- Continue home medications"][text name="variable_1" default=""]
[checkbox name="htnplanstart" value="- Treatment started today based on BP"][text name="variable_medst" default=""]
[checkbox name="htnplanmedno" value="- Patient is not on medications"]
Follow up:
[checkbox name="htnplanfu" value="- Patient should follow up with PCP after discharge"]
[checkbox name="variable_nomedhtn" value="- Will reevaluate BPs after detox to assess further need for long term medication."][/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 2 diabetes mellitus with neuropathy|Type 1 diabetes mellitus without complications|Type 1 diabetes mellitus with hyperglycemia|Other specified diabetes mellitus|Prediabetes"]
Goals:
[checkbox name="dmplangoa1" value="- Goal A1c between (7%-8%)"]
[checkbox name="dmplangoal" value="- Patient is at goal"]
[checkbox name="dmplannogo" value="- Patient is not at goal"]
2. Medication:
- Current Medication includes: [text name="variable_dmmed2" default=""]
[checkbox name="dmplanmedno" value="- Patient is not on medications"]
Monitoring:
- [select name="variable_1520" value="|Patient is electing not to monitor blood glucose|Monitor BG QIDAC+HS|Monitor BG QIDAC+HS+snacks|Monitor BG BID|Monitor BG TID|Monitor BG QID|Monitor BG QD|Monitor BG QWeekly"]
Lifestyle changes:
[checkbox name="dmplangoa2l" value="- Patient was educated about healthy diets, regular exercises, weight control, and reduction of sodium and alcohol intake. Advised quitting smoking if applicable"]
Follow up:
[checkbox name="dmplanfu" value="- Patient should follow up with PCP after discharge"]
[/conditional]
[checkbox memo="Seizure" name="If_sz" value=""][conditional field="If_sz" condition="(If_sz).is('')"]# [select name="sxhx" value="|History of seizure-like activity|Other seizure| Convulsions|Seizure History|Alcohol withdrawal seziure| Pseudo-seizure|Non-epileptic behavioral event|"]
[checkbox name="variable_sxhxss" value="- 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|- Nursing to monitor CIWAs/CWS and Vitals"]
-[checkbox name="variable_sxhxr" value="Medications Rx'd to aid with alcohol withdrawal seizures."] [/conditional]

[comment memo="OTHER MEDICAL CONDITIONS-PLAN OF CARE"]
[textarea name="variable_MED" default=""]

[comment memo="COMMON STATEMENTS:
- no acute findings
- no acute concers
- 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="Psychiatric Conditions" name="If_psychpoc" value=""][conditional field="If_psychpoc" condition="(If_psychpoc).is('')"]# [text name="variable_psychillnes" default="Depression"]
- Defer to psych for evaluation 
- Monitor for any changes in the patient's mood, behavior, or suicidal ideation.
- [select name="variable_psychmeds22" value="|continue home meds on  admission|psychiatry to restart home medications"]
-  [checkbox name="variable_adhdmed2" value="Provider discussed  with the patient that the psychiatric team will evaluate use of narcotic   medication and restart if found necessary"] [/conditional]
[checkbox memo="Suicide Risk" name="If_sic" value=""][conditional field="If_sic" condition="(If_sic).is('')"] [select name="sxsicurrent" value="|# Moderate Suicide Risk|# High Suicide Risk|# Suicidal ideation|# Recent suicide attempt|# Self-harm ideation|# Recent self-harm attempt"]
[checkbox memo="If Moderate or High Risk" name="If_sic2" value=""][conditional field="If_sic2" condition="(If_sic2).is('')"]
-- Suicide Risk Summary -- 
Pt reported they are [checkbox value="not|actively|passively"] suicidal, with [checkbox value="no|firm|vague|lethal|nonlethal|undisclosed"] plans to end their life. The patient verbally confirmed they [checkbox value="have no intention to  commit suicide|intend to die|have ambivalent feelings about suicide"].[checkbox name="prosu" value="-- Protective Factors --"][conditional field="prosu" condition="(prosu).is('-- Protective Factors --')"] 
[checkbox value="treatment responsiveness|connectedness to individuals, family, community, and social institutions|problem-solving skills|coping skills|ability to adapt to change|they sense of purpose or meaning in life Cultural, religious, or personal beliefs that discourage self-injury|good social skills|ability to manage feelings of anger|good health|access to mental and physical health care|healthy fear of risky behaviours and pain|hope for the future and optimism|sobriety|medical compliance|a sense of the importance of health and wellness|impulse control|they strong sense of self-worth or self-esteem|a sense of personal control or determination|access to a variety of clinical interventions and support for seeking help|resiliency|expressed reasons for living|being married|being a parent|strong relationships, particularly with family members|opportunities to participate in and contribute to school or community projects and activities|living in a reasonably safe and stable environment|having restricted access to lethal means|sense of responsibility and duty to others|being a pet owner"][/conditional]
[checkbox name="acute" value="-- Acute Risk Factors --"][conditional field="acute" condition="(acute).is('-- Acute Risk Factors --')"] 
[checkbox value="current suicidal ideation|current suicidal plan|plan lethality|preparation behahiours|vocalising threat to suicide|rehearsal behaviours|recent suicide attempt|regrets not dying|acute mood disorder|current substance abuse|increased substance abuse|mood lability|suicide command hallucinations|insomnia|persistent nightmares|unremitting pain|persistent distress|persistent agitation|tearful|guarded|withdrawal from services|comorbid MH concerns|feelings of hopelessness|severe anhedonia|severe depression|loss of self-esteem|feelings of shame|feeling intolerably alone|feeling trapped|no reasons for living|loss of purpose and meaning|increased impulsivity|increased recklessness|increased anger|seeking revenge|recent violent behaviours|final act behaviours|stalking|intense jealousy over ex|recent loss of relationship|loss of social support|recent discharge from MHIPU|loss of job|financial pressure|loss of status|suicide of close friend|declining health|pending legal issues|pending criminal charges|being victimised"][/conditional]
[checkbox name="stat" value="-- Static Risk Factors --"][conditional field="stat" condition="(stat).is('-- Static Risk Factors --')"] 
[checkbox value="Hx of denying the need for service contact|Hx of avoiding of service contact|non-responsiveness to pharmacological treatment|non-responsiveness to psycho-social interventions|recent discharge from a psychiatric facility|chronic stressors|a history of self-harm|a history of previous suicide attempts|previous hospitalization for suicidality|previous hospitalization for self-harm|Hx of psychiatric illness|Hx of substance abuse|unstable personality structure|a background of childhood adversity|having a family history of suicide|divorced|demographic - male - single age 35-64|problem-solving difficulties|Hx of impulsive behavior|Hx of reckless and self-endangering behaviors|Absolutistic thinking|Tunnel vision|Limited capacity for self-soothing|Perfectionism|sexual orientation rejected by family|Guns in the home|access to abundant medications|chronic medical illness|chronic pain"][/conditional]
[checkbox name="Dyna" value="-- Dynamic Risk Factors --"][conditional field="Dyna" condition="(Dyna).is('-- Dynamic Risk Factors --')"] 
[checkbox value="untreated mental illness|suicidal thinking|intoxication|SI only with intoxication|homelessness|personality disorder|lack of distress tolerance skills|lack of therapeutic alliance|has access to lethal means|withdrawal from support groups|treatment compliance|abuse of substances|psycho-social stressors|problem-solving|feelings of hopelessness|feelings of anger|lack of professional skills|unmet needs"][/conditional].
[/conditional]
Risk Management Recommendations for Patient
[select name="variable_si78" value="|- Considering the totality of both protective and risk factors, it would be appropriate to reclassify the patient's suicide risk level from high to moderate"]
- continue suicide screenings qshift
- Monitor for any changes in the patient's mood, behavior, or suicidal ideation
- If patient leaves AMA, recommend f/u with law enforcement for wellfare check
[checkbox memo="Acute Transfer" name="If_trf" value=""][conditional field="If_trf" condition="(If_trf).is('')"]
[checkbox value="transfer to higher level hospitalization for imminent risk for suicide|immediate assessment with MH professional|remove lethal means| 1:1 monitoring by staff until transfer|inform family of risk|alert supportive individuals|RNs to complete safety plan"][/conditional]
[/conditional]

[checkbox memo="Tobacco Use" name="If_smoke" value=""][conditional field="If_smoke" condition="(If_smoke).is('')"]# [checkbox name="nic" value="Nicotine Use Disorder"]
[checkbox name="cess" value="[select name="variable_4" value="-Behavioral options for quitting reviewed. NRT in place|- Behavioral and Pharmacological options for quitting were reviewed. Does not wish to quit at this time"][/conditional]
[checkbox memo="Sleep Management" name="If_sep" value=""][conditional field="If_sep" condition="(If_sep).is('')"] [select name="variable_2024slep" value="# Insomnia secondary to alcohol use|# Sleep Management|# Insomnia"]
[select name="variable_326841" value="- Rx'd the following sleep medications:|- Patient has declined sleep medications|"]
 [checkbox name="sleepad" value="Trazodone 50mg|Trazodone 100mg|Melatonin|Mirtazpine|Belsomra|Quiviviq|Seroquel|Ambien|Hydroxyzine"][text name="variable_med342" default=""][/conditional]
[checkbox memo="Obesity" name="If_bmi" value=""][conditional field="If_bmi" condition="(If_bmi).is('')"]# [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"][/conditional]
[checkbox memo="Sexually Transmitted Infections" name="If_sti" value=""][conditional field="If_sti" condition="(If_sti).is('')"]# [select name="stdhr" value="||High Risk Sexual Behavior|Screening for STDs"]
[checkbox name="variable_stdhr" value="Patient is not expericing any current symptoms, but is requesting STI testing"]
[checkbox name="variable_stdhrx" value="- No risk factors indentified"]
[checkbox name="variable_stdhrx1" value="- R/F include multiple partners, new partners, unprotected sexual encounters, known + partners"]
[checkbox name="variable_stdhrx2" value="- Will conduct testing (see 'labs collected on admission'), pending findings to inform further management"]
-[link url="https://www.mdcalc.com/denver-hiv-risk-score" memo="Denver High Risk Score"][text name="stdhr" default=" "][/conditional]

[select name="HealthMain" value="HEALTH MAINTENANCE||"]
[checkbox memo="Other viral diseases" name="hep" value=""][conditional field="hep" condition="(hep).is('')"]
[checkbox name="variable_heppanel2" value="# Screening for other viral diseases"]
- [checkbox name="variable_hep232" value="Will conduct hepatitis panel screening for"] [select name="variable_20232" value="health maintence|at-risk behaviors"][/conditional]
[checkbox memo="METS" name="If_METS" value=""][conditional field="If_METS" condition="(If_METS).is('')"] # Screening for metabolic syndromes (MetS) secondary to substance use (ICD code Z13.228)
- The patient is at [select name="variable_riskasses" value="high risk|moderate risk|low risk"] for MetS and further co-morbid complications
- Risk factors include: [text name="variable_rfhm" default=""]
- ASCVD:[link url="https://www.mdcalc.com/calc/3398/ascvd-atherosclerotic-cardiovascular-disease-2013-risk-calculator-aha-acc" memo="ASCVD"] [text name="variable_asvcd" default="unable to determine"]
- American Diabetes Association (ADA) Risk Calculator: [link url="https://www.mdcalc.com/calc/4020/american-diabetes-association-ada-risk-calculator" memo="ADA"] [select name="variable_adadm" value="high risk|moderate risk|low risk|unable to determine"]
- Fib-4: [link url="https://www.hepatitisc.uw.edu/page/clinical-calculators/fib-4" memo="Fib-4"] [select name="variable_utdfib" value="unable to determine|see above"][text name="Fib4" default=""]
-[select name="variable_advlab" value="| will complete further labs to determine extent of hepatic functioning|will complete further labs to determine extent of hepatic functioning and will conduct HgbA1c and lipid panel labs for preventative health measures"]
[/conditional]
[checkbox memo="vaccinations-seasonal" name="If_vac" value=""][conditional field="If_vac" condition="(If_vac).is('')"] # Vaccinations 
[checkbox name="variable_vac1" value="- Influenza vaccine:"] [select name="variable_vac" value="|declined|accepted|already recieved PTA"]
[checkbox name="COVID" value="- Patient agreeable to receiving COVID-19 vaccination; will arrange appointment and transportation"][/conditional]
__________________
MEDICAL CLEARANCE:
This patient is medically cleared to participate in therapeutic programming as tolerated.
[checkbox name="variable_crossfit" value="It is recommended that this patient does not participate in the crossfit elective"]
[comment memo="except for:"][textarea name="variable_1" default=" "]

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."]
__________________
The above plan will be discussed with the patient and modified as necessary based on the patient's progress and feedback. Regular follow-ups will be scheduled to monitor the patient's progress and adjust the treatment plan based on evolving needs. [checkbox name="variable_avs" value="After visit summary was formulated and given to the patient"]
[text name="variable_timeof" default=""] minutes of time was spent on dedicated patient care, documentation, and patient-related tasks before and after visits.
Provider Name: Dr. Claire Baweja, DNP, APRN, FNP-C, CEN, SANE-A
Patient name:
DOB:
Date of visit:
Time of visit:

CC: precipitating event

HPI:
is a -year-old , ,
. This patient was voluntarily admitted to Northpoint Nebraska on for in the context of

Patient denies acute pain or medical concerns. and patient is not in acute distress.

Functional impairments caused by SUD:
- Interpersonal functioning
- Psychological functioning
- Inability to live without recurrent abuse of chemicals

Current Psychiatric Status
Symptomlogy on admission
Substance Use History
__________________
PMH:
Allergies:
Medical conditions:

Diabetes
Hypertension

Psychiatric history:
- Diagnosis:
-
- History of psychiatric inpatient treatment:
- History of SI/SA/SH:
- History of homicidal ideation or attempt:
- History of violence to others (in the last 6 months):
Psych History

female only
__________________
PAST SURGICAL HISTORY:


PREVIOUS HOSPITALIZATIONS:

__________________
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:
Seasonal Influenza
__________________
FHx:






SHx:
-Family Constellation: Patient has . Patient is
- Residence:
- Financial support: Patient is
- Legal Issues:

- Tobacco Use:
- Trauma history:
.
.
- Diet:
- Safety:
__________________
ROS: 12-point system reviewed; Pertinent negatives and positives discussed in HPI.
__________________
PE:
Vital signs reviewed.

General: A&O x3, , ,
Skin: No rash noted. with normal turgor. See body diagram
Head: Head is NC/AT. Scalp is without lesions.
EENT: PERRLA, EOMI, pupils , . 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: Full ROM. Trachea is midline.
Pulmonary: Air entry normal. Breathing unlabored. Lungs CTA bilaterally without adventitious sounds.
CV: RRR w/ no appreciable m/r/g. No peripheral or generalized edema. +2 pulses in upper and lower extremities
GI: Soft, . No organomegaly or masses noted. . . . Bowel sounds present.
MSK: Bilateral upper/lower extremities: symmetric, adequate muscle tone with 5/5 muscle strength, full ROM. No CVA tenderness
Neuro: CNs 2-12 grossly intact. Speech is . . UE and LE DTRs 2+ & equal B/L; No orthostasis.
PSYCH/MSE:
--Behavior - general: .
--Behavior - interactivity: .
--Behavior - eye contact: .
--Mood/Affect: .
--Mood/Affect - emotional range: .
--Mood/Affect - intensity: .
--Mood/Affect - congruence: .
--Thought form and process: ,
--Though Content:
--Attention: .
--Perception - insight:
--Perception- general:
--Cognition/Memory: .
--Judgment: .
--Risk: .
__________________
DIAGNOSTICS:
Breathalyzer testing on admission -
PAWSS -




__________________
A&P
Problem List
Disposition
Reason for Admission: This patient is here for voluntary admission for medically-managed withdrawal and recovery in a protected environment. Throughout the course of this admission, this patient will participate and benefit from a structured intervention program. This program is designed with a focus on educating the patient about the complexities of substance use, approaching it as a disease. This program will also provide therapy to address and enhance interpersonal effectiveness, coping mechanisms, and emotional regulation.
__________________
ACTIVE PROBLEMS/MEDICAL PLAN:
Substance Use Withdrawal
#
Monitoring:
-- Facility status:
-- Continue to monitor recovery in a protected environment
-- Continue psychiatric-medical team collaboration, and update interdisciplinary team
Medication:
--Comprehensive evaluation was completed to determine suitable medication-assisted treatment (MAT) based on the patient’s substance use and overall health. The risks and benefits of MAT medications have been explained to this patient. This patient has been provided education regarding this medication. .
--
Therapy:
-- Initiate individual and group therapy sessions for substance use disorder and encouraged maximal attendance
Aftercare Planning:
-- Explore options for long-term sobriety support, including inpatient rehabilitation and sober living
-- MMDR
MAT

FENGI
Liver Conditions
Fib-4
Hypertension
Diabetes
Seizure

OTHER MEDICAL CONDITIONS-PLAN OF CARE


COMMON STATEMENTS:
- no acute findings
- no acute concers
- 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


Psychiatric Conditions
Suicide Risk

Tobacco Use
Sleep Management
Obesity
Sexually Transmitted Infections


Other viral diseases
METS
vaccinations-seasonal
__________________
MEDICAL CLEARANCE:
This patient is medically cleared to participate in therapeutic programming as tolerated.

except for:


CONTINUING PROBLEM LIST:

__________________
The above plan will be discussed with the patient and modified as necessary based on the patient's progress and feedback. Regular follow-ups will be scheduled to monitor the patient's progress and adjust the treatment plan based on evolving needs.
minutes of time was spent on dedicated patient care, documentation, and patient-related tasks before and after visits.

Result - Copy and paste this output:

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