SUD-FNP Medical F/U

CAUTION: This page needs to be reviewed and categorized.
CC: [checkbox name="variable_cc" value="weekly medical progress note| daily medically-managed detox progress note (per protocol)"]

HPI:
MEDICAL CONCERNS:
[textarea name="concerns" default=" "]
[checkbox name="medcc" value="Patient denies any current subjective complaints or acute medical concerns|Patient denies any adverse effects to medications|This patient is not demonstrating any medically concerning, post-acute withdrawal symptoms"]
[checkbox memo="MEDICAL DETOX" name="If_detox" value=""][conditional field="If_detox" condition="(If_detox).is('')"] MEDICAL DETOX: 
Current Medication includes:[checkbox name="variable_med1" value="librium|ativan|suboxone|diazepam|ativan PRN|oxazepam|gabapentin|tegretol"]
Taper day: [text name="variable_tap" default=""]
Withdrawal symptoms include:  [text name="variable_sx" default="anxiety"].
Withdrawal scores:[text name="variable_wds" default="CIWA/ CWS"][/conditional]
RECOVERY:  
[checkbox memo="Depression" name="dep" value=""][checkbox memo="Anxiety" name="anx" value=""][checkbox memo="Sleep" name="If_sa" value=""][checkbox memo="Cravings" name="If_cr" value=""][checkbox memo="Appetite" name="If_ap" value=""]
[conditional field="anxiety" condition="(anxiety).is('')"][/conditional][conditional field="dep" condition="(dep).is('')"]
Depressive symptoms: Depressive symptoms are reported to be [select value="low|variable|medium| high| present, but stable|present and unstable|stable|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="continuation of current medications|recent medication changes|lack of response to medications|situational stressors|adjustment to environment|engaging with peers|grief|cravings for substances|incorporation of self-care|engaging in individual therapy|engaging in group therapy|decrease in use or abstaining from substance use|detox symptoms|practicing coping skills| lack of coping skills| trauma"].[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"][/conditional]
[conditional field="anx" condition="(anx).is('')"]Anxiety symptoms: Anxiety is reported to be [select value="low|variable|medium| high| present, but stable|present and unstable|stable|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="continuation of current medications|recent medication changes|lack of response to medications|situational stressors|adjustment to environment|engaging with peers|grief|cravings for substances|incorporation of self-care|engaging in individual therapy|engaging in group therapy|decrease in use or abstaining from substance use|detox symptoms|practicing coping skills| lack of coping skills| trauma"]. Anxiety is reported to be present [select value="occasionally|mostly around situational stressors|almost never|about 50% of the time|most of the time on most days|almost always|"][/conditional]
[conditional field="If_sa" condition="(If_sa).is('')"]Sleep is reported to be [select value="stable|unstable|varying daily|stagnant|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| with difficulties falling asleep| with difficulties with frequent awakenings|with difficulties staying asleep|with difficulties with nightmares "][checkbox value="continuation of current medications|recent medication changes|lack of response to medications|situational stressors| detox symptoms|lifestyle improvements|engaging in individual therapy"][textarea].[/conditional]
[conditional field="If_cr" condition="(If_cr).is('')"]Cravings: [select name="variable_cr" value="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|cravings are moderate due to both external and internal triggers"][/conditional]
[conditional field="If_ap" condition="(If_ap).is('')"]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"][/conditional]
This patient is [select name="variable_6" value="polite and cooperative|interactive|limited in their engagement with this conversation| polite, but has with limited engagment in this conversation| withdrawn|guarded|hostile|questioning|demanding|agitated|anxious|tearful|manic presenting|dysregulated|dysthymic|euthymic|irritable"]. Over this last week, this patient's progress can be characterized as [select name="variable_1" value="making positive progress|declined in progress|stagnant|showing improvement|minimal|minimal due to resistance"] in learning to use coping skills to handle stress, and anxiety, and modify habits.  
This patient does benefits from admission in a protected environment for medication management, education, and development of coping skills to prevent relapse.
[checkbox memo="Barriers/Strengths" name="bs" value=""]
[conditional field="bs" condition="(bs).is('')"][checkbox value="Barriers to success include: "][checkbox value="current apprehension to engage in psychopharmaceutical intervention|current apprehension to engage in structured psychotherapy|current substance use|limited social supports|dysfunctional interpersonal relationships"]. [checkbox value="Patient strength for success include: "][checkbox value="expression of willingness to engage in treatment recommendations|positive social supports|strong therapeutic rapport|daily medication compliance"][/conditional]
____________________________________ 
Review/ Management:     
I reviewed the following information: medical hx, medications, allergies, physical exams and progress notes, V/S     
I obtained collateral information from:  Nursing    
_________________________________________
ROS: Pertinent Neg and Pos discussed in HPI 
___________________________________________ 
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:    
# Recovery 
Pt continues to benefit from admission in a protected environment to prevent relapse.   
Continue and Monitor:    
*Encourage to engage in group sessions, individual therapy sessions, and outings per treatment plan    
*Coordinate treatment with psychiatric team  
*Encourage engagement in ongoing relapse prevention and aftercare plan    
*Continue to monitor recovery in a protected environment    
[checkbox memo="Admission Labs" name="labs" value=""][checkbox memo="MAT" name="mat" value=""]
[textarea name="medPOC" default=""]
[conditional field="labs" condition="(labs).is('')"]
# ADMISSION LABS  
- see progress note for interpretation 
- see PHI for lab results  [/conditional]

[conditional field="mat" condition="(mat).is('')"]
# Medication-Assisted Treatment 
Risk and benefits of this MAT medications have been explained to this patient. 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]
CC:

HPI:
MEDICAL CONCERNS:


MEDICAL DETOX
RECOVERY:
Depression Anxiety Sleep Cravings Appetite





This patient is . Over this last week, this patient's progress can be characterized as in learning to use coping skills to handle stress, and anxiety, and modify habits.
This patient does benefits from admission in a protected environment for medication management, education, and development of coping skills to prevent relapse.
Barriers/Strengths

____________________________________
Review/ Management:
I reviewed the following information: medical hx, medications, allergies, physical exams and progress notes, V/S
I obtained collateral information from: Nursing
_________________________________________
ROS: Pertinent Neg and Pos discussed in HPI
___________________________________________
PHYSICAL EXAMINATION:
[VSS and patient asymptomatic]
Constitutional: cooperative, ,
Neuro:
Respiratory: lung sounds clear, no accessory muscle use
Cardiac: RRR, no m/r/g,
GI: abdomen soft, non-distended, non-tender. Bowel tones normoactive
Psych:

ASSESSMENT/PLAN:
# Recovery
Pt continues to benefit from admission in a protected environment to prevent relapse.
Continue and Monitor:
*Encourage to engage in group sessions, individual therapy sessions, and outings per treatment plan
*Coordinate treatment with psychiatric team
*Encourage engagement in ongoing relapse prevention and aftercare plan
*Continue to monitor recovery in a protected environment
Admission Labs MAT



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Sandbox Metrics: Structured Data Index 0.86, 54 form elements, 174 boilerplate words, 3 text boxes, 3 text areas, 20 checkboxes, 18 drop downs, 10 conditionals, 99 total clicks
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