Individual Therapy Session

[select name="Q1" value="Intake/Assessment|Orientation|Crisis Intervention|Psychotherapy"][conditional field="Q1" condition="(Q1).is('Intake/Assessment')"]
[textarea default="BioSocial History"]
[textarea default="Interview and Assessment overview"]
[textarea default="Mini-Mental Status Exam:Cognition,Speech,Thoughts,Presentation,Mood/Affect"]
[textarea default="Orientation: Overview of Dialectical Behavior Therapy Model:"][/conditional][conditional field="Q1" condition="(Q1).is('Orientation')"]
[textarea default="Where in orientation is client?"]
Has client defined their life worth living goal?
[select name="Q2" value="Yes|No|In Progress"][conditional field=Q2 condition="(Q2).is('Yes')"]
[textarea default="What is there life woth living goal?"][/conditional]

[conditional field="Q1" condition="(Q1).is('Crisis Intervention')"]
[textarea default="Describe Crisis and Interventions Offered"]
Was a safety Plan created?
[checkbox name="Q5" value="Yes|No"][conditional field="Q5" condition="(Q5).is('No')"][textarea name="Q6" default="If no safety plan ceated, explain reasoning"][/conditional]

[textarea default="Neck: Range of motion with normal flexion, extension, right rotation, and left rotation.  There is no palpable paraspinal muscle spasm."]
[textarea default="Shoulder:  Symmetrical bilaterally, FROM flex/ex/IR/ER/abduction/adduction, No erythema or edema, Nontender to palpation, Negative:  Hawkins, Neers, Yergusons, Speeds, empty can, 5/5 strength biceps/triceps/grip, Radial pulse full. Cap refill <2 seconds, Sensory intact to light touch distally."][/conditional][conditional field="Q1" condition="(Q1).is('Psychotherapy')"]
[textarea default="General Appearance: no acute distress
[textarea default="Knee: Normal joint contours.  No effusion.  Normal range of motion.  Normal strength on extension and flexion against resistance.  No joint line pain medially or laterally.  McMurray negative for crepitus and pain medially and laterally.  There is no swelling or pain over the pes anserine bursa.  Collateral ligament testing shows no laxity or pain.  Anterior drawer test and Lachman shows no anterior cruciate laxity.  Posterior drawer negative for laxity as well. No popliteal mass or palpable tenderness."][/conditional]


Has client defined their life worth living goal?


Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.21, 20 form elements, 1 boilerplate words, 11 text areas, 1 checkboxes, 2 drop downs, 6 conditionals, 15 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: