SUD-FNP Medical F/U

CC:[radio name="variable_cc" value="weekly monitoring for medical status|daily medical monitoring and follow-up per detox protocol"]

HPI:
MEDICAL CONCERNS:
[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"][textarea name="concerns" default=" "]
[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"][/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="stable|significantly better|somewhat better|somewhat worse|much worse| "].  [select value="||Current stability 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|situational stressors|incorporation of self care|engaging in individual therapy|decrease in use or abstaining from substance use"].[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="stable|significantly better|somewhat better|somewhat worse|much worse| "].  [select value="||Current stability 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|lifestyle improvements|engaging in individual therapy"]. 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|better|somewhat better|somewhat worse|much worse| "].  [select value="|Current stability 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|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_cr" value="denies any changes or concerns with appetite|reports poor appetite| reports flucuation in appetite| reports eating disorder disturbance"][/conditional]
This patient is [select name="variable_6" value="polite and cooperative|interactive|withdrawn|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 progress|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"], [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: A&O   
Respiratory: lung sounds clear, no accessory muscle use    
Cardiac: RRR, no m/r/g, no edema    
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=""]
[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 Naltrexone/ Vivitrol at this time| This patient accepts Naltrexone/ Vivitrol at this time| This patient is still deciding on MAT| This patient accepts acamprosate"] [/conditional]