Patient Note Snippets Flashcards

Question

.nlmem

Answer 1

Recent memory is intact. Remote memory is intact.

Answer 2

Alert and oriented to person, place, time and situation.

Answer 3

Coherent and normal rate, volume and articulation.

Answer 4

No abnormal thought content, no auditory or visual hallucinations, no paranoid ideations or delusions.

Answer 5

Linear, Logical. Goal directed. Organized.

Answer 6

Patient is not taking care of their activities of daily living (ADLs), Such as bathing, basic grooming, changing their clothes.

Answer 7

The patient is not participating in any unit groups or activities. The patient has been isolating themselves in their room.

Answer 8

See original H&P for specific values (no significant abnormalities)

Answer 9

The patient did not have any active medical conditions that required treatment during his hospital stay.

Answer 10

No-Show, No-Call
Documented %1I:%M %p , %snippet:ddate%.

Answer 11

Prepare for discharge in the morning.

Answer 12

Medications

Start:

Continue:

Discontinue:

Lifestyle/Behavior Modifications:

Follow up In: 2 Months

Patient Instruction/Education Provided: Regarding medication risks and benefits; potential side effects, expectations of symptom reduction, signs of adverse reactions.

Patient was provided with instructions regarding diagnosis and recommendations. Questions were welcomed and answered.

Answer 13

Prior outpatient treatment: Hospitalizations: Notable Prior Medication Trials: Suicide Attempts:

Answer 14

REBOUND BEHAVIORAL HEALTH®

PSYCHIATRY PROGRESS NOTE Patient Identification

Date and Time of Examination: Saturday, May 9, 2020

INTERVAL HISTORY

Chief Complaint (“in the patient’s own words”):

“ “

History of Present Illness/Clinical Status

Mr. Johnson reports that he was picked up by the police after threatening to ingest 50 tablets of alprazolam.

Past Family and Social History:

No Changes since last visit

MENTAL STATUS EXAMINATION

Appearance: Moderately well groomed, no abnormal appearance

Orientation: Alert, Oriented to person, place and situation

Motor: No abnormal movements

Mood: Depressed

Affect: Flat, restricted range, Congruent with mood

Speech: RRR, Decreased Volume, Coherent

Language: Fluent

Thought Process: Linear, Logical, Goal Directed

Though Content: No A/V/T Hallucinations, No Delusions

Risk Factors: Suicidal Ideation (with a plan); Homicidal Ideation (with a plan)

Concentration: Normal (Focused) ; How Tested: Per observation of the patient and interview

Recent Memory: x out of 3 in 3 mins

Remote Memory: past events, personal history

Insight: Fair; relative to patient's understanding of severity of illness

Judgment: Fair; Per patient's behavior

Intelligence: Average, Based on vocabulary, syntax, grammar and content.

*Explain Abnormal Findings:

ASSESSMENT & MEDICAL DECISION MAKING

Diagnosis/Impressions:

Plan and Medication Changes/Indications:

Lab Studies, other data:

Response to Treatment:

Not achieving treatment goals

Has achieved some treatment goals, but still in process

Treatment goals achieved and patient stable for discharge or step down.

Estimated Date of Discharge:

Reason for Continued Hospitalization:

Suicidal Ideation Danger to Self or Others

Severe Impairment of Level of Functioning Medication Stabilization Discharge May Exacerbate Illness

Severe Depression/Anxiety Post-Acute Detox Symptoms Behavior Requires 24 Hr. Supervision

Severely Impaired Disorder- Thoughts Perception

Signature: ________________________________________________ Date: __________________ Time: _____________

Answer 15

Dr. Strother will be out of the office on %filltext:name=dates out:width=20:default=%.
He will return next week.

We apologize for the inconvenience.
Unfortunately you will have to reschedule your appointment.
Please contact the Matthews office at 704-360-3637

Sincerely,

Lifestance - Matthews

Answer 16

responding to internal stimuli

Answer 17

Resides:
Highest level of education:
Employment:
Marital Status:
Children:
Pets:

Answer 18

suicidal ideation

Answer 19

%fillpopup:name=Type of Sleep:default=Good Sleep: The patient reports that they are sleeping well, easy to get to sleep no difficulty remaining asleep. Averages 7-8 hrs/night. Denies nightmares.:Poor Sleep: difficulty getting to sleep, difficulty remaining asleep, averages approximately 5 to 6 hrs / night:Difficulty getting to sleep; averages 5-6 hrs/night:Difficulty Staying asleep, averages about 5-6 hrs/night%

Answer 20

Seeking medication management.

Answer 21

Tobacco:

Alcohol:

Drug history:

Urine drug screen (+):

Answer 22

Patient describes difficulty remaining focused at work and some task oriented activities in the home. Describes being easily distractible, Frequently resulting in procrastination and frequent interruptions. Finds it difficult to maintain concentration for an extended period of time in the workplace and at home. Occasional episodes of hyperactivity, Overall generally inattentive.

Answer 23

The patient has demonstrated the capacity and willingness to participate in voluntary treatment.

Answer 24

Patient educated about potential withdrawal symptoms from the abrupt discontinuance of benzodiazepines, informed that fixed, stable dosing would reduce dependence and abuse issues compared to PRN dosing. Patient informed about the risks of consuming alcohol or other sedating medications with benzodiazepines.

Answer 25

The Ketamine treatment I would recommend only in severe treatment resistant depression cases, Much like ECT. Too many practitioners in my opinion, seem to be modeling the treatment after Suboxone clinics. Its supposed to give you "lift " out of severe depression, but not be a maintenance treatment. Sincerely, Dr. Strother

Answer 26

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%snippet:.hpi%

Answer 27

Smell: Intact Vision: Normal acuity Extra-ocular movements: Intact, no deviations, no nystagmus Pupils: Equal, Round, Reactive to light Facial Symmetry: No abnormalities Tongue protrudes in midline SCM strength: Normal (Bilaterally) Shoulder raise: Intact Finger to Nose: No cerebellar dysfunction noted Upper extremity strength: 5/5 Lower extremity strength: 5/5 Gait: Normal Reflexes Patellar - Normal Dyskinetic Movements: None

Answer 28

Skin: Warm, no significant lesions; Head: Normocephalic, no lesions; Facial Symmetry: No abnormalities; Eyes: Pupils Equal, Round, EOM: Intact, no deviations, no nystagmus; Ears: normal Pinna, No discharge; Nose: Clear, no deformity; Mouth and Dentition: No abnormalities, Tongue protrudes in midline, throat clear; Neck: Full ROM, Normal SCM strength; Chest Wall: No abnormal movements; Lungs: Clear to auscultation in upper and lower lung fields; Cardiac: RRR, No Murmurs; Abdomen: Soft, No discomfort; Back and Spine: Non-tender; Extremities: Full ROM, normal strength (upper and lower - 5/5 bilaterally), No cerebellar dysfunction noted; Gait: Normal; Dyskinetic Movements: None Observed

Answer 29

Skin: Warm, no significant lesions Head: Normocephalic, no lesions Facial Symmetry: No abnormalities Eyes: Pupils Equal, Round, EOM: Intact, no deviations, no nystagmus Ears: normal Pinna, No discharge Nose: Clear, no deformity (mouth and dentition): No abnormalities, Tongue protrudes in midline, throat clear Neck: Full ROM, Normal SCM strength: Shoulder raise: Intact Chest Wall: No abnormal movements Lungs: Clear to auscultation in upper and lower lung fields Cardiac: RRR, No Murmurs Abdomen: Soft, No discomfort Back and Spine: Non-tender Extremities: Full ROM, nl strength (upper and lower - 5/5 bilaterally) No cerebellar dysfunction noted Gait: Normal Dyskinetic Movements: None Observed

Answer 30

Head: No complaints Eyes: No complaints Hearing: No complaints Nose: No complaints Mouth/throat: No complaints Cardiovascular: No complaints Respiratory: No complaints Gastrointestinal: No complaints Musculoskeletal: No complaints Skin: No complaints Weight change/dietary habits: No complaints

Answer 31

No medication changes indicated at this time.

Answer 32

New hpi template for AMD

Patient Note Snippets Flashcards

(56 cards)