Patient Note Snippets Flashcards

Question 1

Q

.amdcc

Answer

A

Patient presents for medication management for %key:tab%%key:tab% %snippet:.hpi%

Question 2

Q

.anxed

Answer

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.

Question 3

Q

.ccm

Answer

A

Continue current Medications

Question 4

Q

.cmm

Answer

A

Continued Medication Management

Question 5

Q

.cot

Answer

A

Presentation on admission:

Initial treatment (Medication management plan):

Patient's condition at the time of discharge:

Medications titrated:

Procedures: none

PRN medication usage: minimal

Restraint/seclusion use: none

Labs/studies:

Patient's response to treatment:

Physical and medical conditions at discharge:

Question 6

Q

.duration

Answer

A

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

Question 7

Q

.energy

Answer

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.%

Question 8

Q

.fmr

Answer

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.

Question 9

Q

.hi

Answer

A

homicidal ideation

Question 10

Q

.hpi

Answer

A

Recent Events:

General Mood:

Prominent Symptoms:

Duration of Symptoms:

Things that improve symptoms:

Things that worsen symptoms:

Energy Level:

Sleep Cycle:

Question 11

Q

.inVegag

Answer

A

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

Question 12

Q

.ltns

Answer

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=%. Please make an appointment with the Matthews office 704-360-3637. Sincerely, Dr. Strother

Question 13

Q

.mood

Answer

A

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

Question 14

Q

.mse

Answer

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%

Question 15

Q

.nac

Answer

A

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

Question 16

Q

.nam

Answer

A

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

Question 17

Q

.nbe

Answer

A

Non-Billable Encounter

Question 18

Q

.nlappear

Answer

A

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

Question 19

Q

.nlass

Answer

A

Intact. No loose associations noted.

Question 20

Q

.nlatt

Answer

A

Focused. Attention span is intact. No concentration difficulties.

Question 21

Q

.nlfund

Answer

A

Intact. No abnormalities noted.

Question 22

Q

.nlgait

Answer

A

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

Question 23

Q

.nlinsi

Answer

A

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

Question 24

Q

.nllang

Answer

A

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

Question 25

Q

.nlmem

Answer

A

Recent memory is intact. Remote memory is intact.

Question 26

Q

.nlorient

Answer

A

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

Question 27

Q

.nlspeech

Answer

A

Coherent and normal rate, volume and articulation.

Question 28

Q

.nltc

Answer

A

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

Question 29

Q

.nltp

Answer

A

Linear, Logical. Goal directed. Organized.

Question 30

Q

.noadls

Answer

A

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

Question 31

Q

.nogroups

Answer

A

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

Question 32

Q

.nolabs

Answer

A

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

Question 33

Q

.nomedical

Answer

A

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

Question 34

Q

.ns

Answer

A

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

Question 35

Q

.pfd

Answer

A

Prepare for discharge in the morning.

Question 36

Q

.plan

Answer

A

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.

Question 37

Q

.pph

Answer

A

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

Question 38

Q

.prognote

Answer

A

REBOUND BEHAVIORAL HEALTH®

PSYCHIATRY PROGRESS NOTE Patient Identification

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

<div>INTERVAL HISTORY </div>

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

<div>MENTAL STATUS EXAMINATION </div>

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: \_\_\_\_\_\_\_\_\_\_\_\_\_

Question 39

Q

.resched

Answer

A

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

Question 40

Q

.ris

Answer

A

responding to internal stimuli

Question 41

Q

.shx

Answer

A

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

Question 42

Q

.si

Answer

A

suicidal ideation

Question 43

Q

.sleep

Answer

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%

Question 44

Q

.smm

Answer

A

Seeking medication management.

Question 45

Q

.suh

Answer

A

Tobacco:

Alcohol:

Drug history:

Urine drug screen (+):

Question 46

Q

.sxadhd

Answer

A

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.

Question 47

Q

.voluntary

Answer

A

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

Question 48

Q

benzorisk

Answer

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.

Question 49

Q

ketopinion

Answer

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

Question 50

Q

nhpi

Answer

A

%snippet:selectallas% %snippet:.hpi%

Question 51

Q

nlneuro

Answer

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

Question 52

Q

nlpeblock

Answer

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; 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

Question 53

Q

nlpelist

Answer

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

Question 54

Q

nlros

Answer

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

Question 55

Q

nmc

Answer

A

No medication changes indicated at this time.

Question 56

Q

Temphpi

Answer

A

New hpi template for AMD