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Text Exander Snippets > Patient Note Snippets > Flashcards

Patient Note Snippets Flashcards

1
Q

.amdcc

A

Patient presents for medication management for <br></br>%key:tab%%key:tab%<br></br>%snippet:.hpi%<br></br>

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2
Q

.anxed

A

Patient education about the role of SSRI therapy and benzodiazepine therapy for management. Discussed the need for fixed dosing of anxiolytic medications. Discussed the importance of avoiding anticipatory anxiety.

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3
Q

.ccm

A

Continue current Medications

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4
Q

.cmm

A

<p>Continued Medication Management</p>

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5
Q

.cot

A

<p><span><span>Presentation on admission:</span></span><br></br></p>

<p><span><span> </span></span><br></br></p>

<p><span><span>Initial treatment (Medication management plan): </span></span><br></br></p>

<p><br></br></p>

<p><span><span>Patient's condition at the time of discharge:</span></span><br></br></p>

<p><br></br></p>

<p><span><span>Medications titrated: </span></span><br></br></p>

<p><br></br></p>

<p><span><span>Procedures: none</span></span><br></br></p>

<p><br></br></p>

<p><span><span>PRN medication usage: minimal</span></span><br></br></p>

<p><br></br></p>

<p><span><span>Restraint/seclusion use: none</span></span><br></br></p>

<p><br></br></p>

<p><span><span>Labs/studies: </span></span><br></br></p>

<p><br></br></p>

<p><span><span>Patient's response to treatment: </span></span><br></br></p>

<p><br></br></p>

<p><span><span>Physical and medical conditions at discharge:</span></span></p>

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6
Q

.duration

A

%fillpopup:name=Duration:> 20 years:default=> 10 years:Since grade school:Since High School:Since College:Lifelong%

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7
Q

.energy

A

%fillpopup:name=Type of Energy:default=”Good”, remains active, no difficulty performing day to day tasks.:”Low to none”; difficulty getting out of bed, feeling tired all day, poor motivation.%

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8
Q

.fmr

A

Patient’s condition is not improving due to the patient’s refusal of all medications and requires the forced administration of the following medications to return her level of functioning back to baseline.

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9
Q

.hi

A

<span><span>homicidal ideation</span></span>

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10
Q

.hpi

A

<p>Recent Events: <br></br></p>

<p><br></br></p>

<p>General Mood:<br></br></p>

<p><br></br></p>

<p>Prominent Symptoms: <br></br></p>

<p><br></br></p>

<p>Duration of Symptoms:<br></br></p>

<p><br></br></p>

<p>Things that improve symptoms:<br></br></p>

<p><br></br></p>

<p>Things that worsen symptoms:<br></br></p>

<p><br></br></p>

<p>Energy Level: <br></br></p>

<p><br></br></p>

<p>Sleep Cycle: </p>

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11
Q

.inVegag

A

Invega Sustenna IM, administered during visit today %m/%d/%y at %I:%1M %p

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12
Q

.ltns

A

Dear %filltext:name=Name:width=20:default=% I have not seen you since our last appointment on %filltext:name=Last Appt:width=20:default=%.<br></br>Please make an appointment with the Matthews office 704-360-3637. <br></br><br></br>Sincerely,<br></br>Dr. Strother

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13
Q

.mood

A

%fillpopup:name=Type of Mood:”Feeling pretty good, I’m doing alright”:default=”Feeling much better since last visit”:”Feeling depressed, kinda sad”%

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14
Q

.mse

A

%snippet:.nlaffect% %key:tab% %key:tab% %snippet:.nlappear%%key:tab% %key:tab% %snippet:.nlgait% %key:tab% %key:tab% %snippet:.nlorient% %key:tab% %key:tab% %snippet:.nlspeech% %key:tab% %key:tab% %snippet:.nllang% %key:tab% %key:tab% %snippet:.nlass% %key:tab% %key:tab% %snippet:.nltp% %key:tab% %key:tab% %snippet:.nlmem% %key:tab% %key:tab% %snippet:.nltc% %key:tab% %key:tab% %snippet:.nlfund% %key:tab% %key:tab% %snippet:.nlatt% %key:tab% %key:tab% %snippet:.nlinsi%

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15
Q

.nac

A

No changes in appetite. Denies any significant changes in weight.

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16
Q

.nam

A

The patient does not have any active medical conditions at this time.

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17
Q

.nbe

A

Non-Billable Encounter

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18
Q

.nlappear

A

Appropriate dress, appropriate grooming and hygiene, appears stated age. No acute distress.

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19
Q

.nlass

A

Intact. No loose associations noted.

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20
Q

.nlatt

A

Focused. Attention span is intact. No concentration difficulties.

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21
Q

.nlfund

A

Intact. No abnormalities noted.

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22
Q

.nlgait

A

Normal gait and upright station. No notable abnormal movements or coordination issues.

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23
Q

.nlinsi

A

Judgment is not impaired. Good insight regarding reason for visit.

24
Q

.nllang

A

Names objects appropriately. Demonstrates understanding. correct and appropriate use of words, with normal sentence structure.

25
Q

.nlmem

A

Recent memory is intact. Remote memory is intact.

26
Q

.nlorient

A

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

27
Q

.nlspeech

A

Coherent and normal rate, volume and articulation.

28
Q

.nltc

A

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

29
Q

.nltp

A

Linear, Logical. Goal directed. Organized.

30
Q

.noadls

A

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

31
Q

.nogroups

A

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

32
Q

.nolabs

A

<span>See original H&P for specific values (no significant abnormalities)</span>

33
Q

.nomedical

A

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

34
Q

.ns

A

No-Show, No-Call<br></br>Documented %1I:%M %p , %snippet:ddate%.

35
Q

.pfd

A

Prepare for discharge in the morning.

36
Q

.plan

A

Medications<br></br> <br></br>Start:<br></br> <br></br>Continue: <br></br> <br></br>Discontinue: <br></br><br></br>Lifestyle/Behavior Modifications:<br></br><br></br>Follow up In: 2 Months<br></br><br></br>Patient Instruction/Education Provided: Regarding medication risks and benefits; potential side effects, expectations of symptom reduction, signs of adverse reactions.<br></br><br></br>Patient was provided with instructions regarding diagnosis and recommendations. Questions were welcomed and answered.

37
Q

.pph

A

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

38
Q

.prognote

A

<p><br></br></p>

<p><span><span><b>REBOUND BEHAVIORAL HEALTH®</b></span></span><br></br></p>

<p><span><span><b>PSYCHIATRY PROGRESS NOTE</b> </span></span><span><span><span>Patient Identification</span></span></span><br></br></p>

<p><br></br></p>

<p><span><span>Date and Time of Examination: Saturday, May 9, 2020</span></span><br></br></p>

<p><br></br></p>

<div><span><span><u>INTERVAL HISTORY</u></span></span><br></br></div>

<p><span><span>Chief Complaint (“in the patient’s own words”):</span></span><br></br></p>

<p><span><span>“ “</span></span><br></br></p>

<p><br></br></p>

<p><span><span>History of Present Illness/Clinical Status</span></span><br></br></p>

<p><span><span>Mr. Johnson reports that he was picked up by the police after threatening to ingest 50 tablets of alprazolam.</span></span><br></br></p>

<p><br></br></p>

<p><span><span>Past Family and Social History:</span></span><br></br></p>

<p><span><span>No Changes since last visit</span></span><br></br></p>

<p><br></br></p>

<div><span><span><u>MENTAL STATUS EXAMINATION</u></span></span><br></br></div>

<p><br></br></p>

<p><span><span>Appearance: Moderately well groomed, no abnormal appearance</span></span><br></br></p>

<p><span><span>Orientation: Alert, Oriented to person, place and situation</span></span><br></br></p>

<p><span><span>Motor: No abnormal movements</span></span><br></br></p>

<p><span><span>Mood: Depressed</span></span><br></br></p>

<p><span><span>Affect: Flat, restricted range, Congruent with mood</span></span><br></br></p>

<p><span><span>Speech: RRR, Decreased Volume, Coherent</span></span><br></br></p>

<p><span><span>Language: Fluent</span></span><br></br></p>

<p><span><span>Thought Process: Linear, Logical, Goal Directed</span></span><br></br></p>

<p><span><span>Though Content: No A/V/T Hallucinations, No Delusions</span></span><br></br></p>

<p><span><span>Risk Factors: Suicidal Ideation (with a plan); Homicidal Ideation (with a plan)</span></span><br></br></p>

<p><span><span>Concentration: Normal (Focused) ; How Tested: Per observation of the patient and interview</span></span><br></br></p>

<p><span><span>Recent Memory: x out of 3 in 3 mins</span></span><br></br></p>

<p><span><span>Remote Memory: past events, personal history</span></span><br></br></p>

<p><span><span>Insight: Fair; relative to patient's understanding of severity of illness</span></span><br></br></p>

<p><span><span>Judgment: Fair; Per patient's behavior</span></span><br></br></p>

<p><span><span>Intelligence: Average, Based on vocabulary, syntax, grammar and content.</span></span><br></br></p>

<p><br></br></p>

<p><br></br></p>

<p><span><span>*Explain Abnormal Findings:</span></span><br></br></p>

<p><br></br></p>

<p><span><span>ASSESSMENT & MEDICAL DECISION MAKING</span></span><br></br></p>

<p><br></br></p>

<p><span><span>Diagnosis/Impressions: </span></span><br></br></p>

<p><br></br></p>

<p><br></br></p>

<p><span><span>Plan and Medication Changes/Indications: </span></span><br></br></p>

<p><br></br></p>

<p><br></br></p>

<p><span><span>Lab Studies, other data:</span></span><br></br></p>

<p><br></br></p>

<p><span><span>Response to Treatment:</span></span><br></br></p>

<p><span><span>Not achieving treatment goals</span></span><br></br></p>

<p><span><span>Has achieved some treatment goals, but still in process</span></span><br></br></p>

<p><span><span>Treatment goals achieved and patient stable for discharge or step down.</span></span><br></br></p>

<p><br></br></p>

<p><span><span>Estimated Date of Discharge:</span></span><br></br></p>

<p><br></br></p>

<p><span><span>Reason for Continued Hospitalization:</span></span><br></br></p>

<p><span><span>Suicidal Ideation Danger to Self or Others</span></span><br></br></p>

<p><span><span>Severe Impairment of Level of Functioning Medication Stabilization Discharge May Exacerbate Illness</span></span><br></br></p>

<p><span><span>Severe Depression/Anxiety Post-Acute Detox Symptoms Behavior Requires 24 Hr. Supervision</span></span><br></br></p>

<p><span><span>Severely Impaired Disorder- Thoughts Perception</span></span><br></br></p>

<p><br></br></p>

<p><br></br></p>

<p><br></br></p>

<p><span><span>Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Time: \_\_\_\_\_\_\_\_\_\_\_\_\_</span></span><br></br></p>

<p><br></br></p>

<p></p>

39
Q

.resched

A

Dr. Strother will be out of the office on %filltext:name=dates out:width=20:default=%.<br></br>He will return next week.<br></br><br></br>We apologize for the inconvenience.<br></br>Unfortunately you will have to reschedule your appointment.<br></br>Please contact the Matthews office at 704-360-3637<br></br><br></br>Sincerely,<br></br><br></br>Lifestance - Matthews

40
Q

.ris

A

responding to internal stimuli

41
Q

.shx

A

<span>Resides: </span><br></br><span>Highest level of education: </span><br></br><span>Employment: </span><br></br><span>Marital Status: </span><br></br><span>Children: </span><br></br><span>Pets:</span>

42
Q

.si

A

<span><span>suicidal ideation</span></span>

43
Q

.sleep

A

%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%

44
Q

.smm

A

Seeking medication management.

45
Q

.suh

A

<p><span><span>Tobacco:</span></span><br></br></p>

<p><span><span>Alcohol:</span></span><br></br></p>

<p><span><span>Drug history:</span></span><br></br></p>

<p><span><span>Urine drug screen (+): </span></span></p>

46
Q

.sxadhd

A

<span><span>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.</span></span>

47
Q

.voluntary

A

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

48
Q

benzorisk

A

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.

49
Q

ketopinion

A

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

50
Q

nhpi

A

%snippet:selectallas%<br></br>%snippet:.hpi%

51
Q

nlneuro

A

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

52
Q

nlpeblock

A

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

53
Q

nlpelist

A

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

54
Q

nlros

A

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

55
Q

nmc

A

No medication changes indicated at this time.

56
Q

Temphpi

A

New hpi template for AMD

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