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| Keyword | Description |
|---|---|
| anx | Patient complains of: Fatigue, muscle tension, irritability, poor concentration, feeling on edge, sleep disruption. |
| bpscale | Digital Wrist Blood Pressure Monitors 120 Reading Memory Clinically Accurate & Adjustable BP Wrist Cuff with Carrying Case and Large LCD Display https://www.amazon.com/Pressure-Monitors-Clinically-Accurate-Adjustable/dp/B07WCS3616/ref=sr_1_23?crid=14UR0N0UNBLHE&dchild=1&keywords=blood+pressure+monitor&qid=1594210869&sprefix=blood+pr%2Caps%2C176&sr=8-23 Etekcity Digital Body Weight Bathroom Scale with Body Tape Measure, Large Blue LCD Backlight Display, High Precision Measurements https://www.amazon.com/Etekcity-Digital-Bathroom-Measure-Tempered/dp/B01HI1W1V4/ref=sr_1_6?dchild=1&keywords=bathroom+scale&qid=1594211118&sr=8-6 |
| carecoord | More than 50% of the visit was spent on counseling and/or coordination care. |
| conduct | A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling. Angry/Irritable Mood 1. Often loses temper. 2. Is often touchy or easily annoyed. 3. Is often angry and resentful. Argumentative/Defiant Behavior 4. Often argues with authority figures or, for children and adolescents, with adults. 5. Often actively defies or refuses to comply with requests from authority figures or with rules. 6. Often deliberately annoys others. 7. Often blames others for his or her mistakes or misbehavior. Vindictiveness 8. Has been spiteful or vindictive at least twice within the past 6 months. |
| dep | Patient complains of: Sleep disruption, loss of interest, feelings of guilt or hopelessness or helplessness, decrease in energy, poor concentration, change in appetite, psychomotor change, suicidal thoughts. |
| dismissal | Dear I regret to inform you that Tulsa Family Psychiatry & Wellness is no longer able to continue providing medical care to you due to If you have any questions about the reason for termination of care, your diagnosis, or have any non-emergent needs within 30 days of the date on this letter, please call our office at 918.268.9578. For emergent needs, please seek your nearest emergency room or urgent care facility. You may wish to consult your primary care doctor for guidance in selecting another provider or you may consider the following options: Family and Children’s Services 918-587-9471 2325 S Harvard Tulsa, Ok 74114 Mind Spa 918-951-2510 3314 E 46th St Ste 200 Tulsa, Ok 74135 To assist you in continuing to receive medical care, we will send medical records to the new provider whom you designate. Please send a request in writing to: Tulsa Family Psychiatry & Wellness 2530 East 71st street Suite B Tulsa OK, 74136-5577 Sincerely, |
| extend | During this encounter, I spent extended face-to-face time with discussing treatment and the next steps we will take in the care plan. |
| hpi | Dx: Started: Quality: Severity: Timing Aggr: Allev: Context: |
| hpipsych | DEPRESSION: Reports loss of interest or sad mood S leep disturbance I interest loss G uilt or shame or hopelessness/helplessness E nergy loss C oncentration loss A ppetite change P sychomotor change S uicidal thoughts MANIA: elevated, expansive mood and or irritable mood and elevated energy Distractible Irritable Grandiosity Flight of ideas Activity increase Sleep need decrease Talkativeness ANXIETY: multiple worries all time about many things for at least 6 mos Fatigue Muscle tension Irritability Concentration loss On edge feeling Sleep disturbance PANIC: Discrete repeated episodes of extreme fear or discomfort, resulting in avoidance/change of activity accompanied by 4 of the following: Shaking or trembling Sweating Shortness of breath Choking sensation Chest pain Racing heart, palpitations, pounding heart Dizziness, feeling faint Tingling or numbness Chills or hot flushes Nausea or upset stomach Feelings of going crazy Feelings of dying, sense of impending doom or terror Derealization TRAUMA: PSYCHOSIS: SLEEP: Eating Disorders: OCD: ODD: CD: ADHD: ASD: RAD: OTHER: |
| mania | Patient complains of: Distractibility, indiscretions, grandiosity, flight of ideas, increased levels of activity, decreased need for sleep, and talkativeness. |
| odd | A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling. Angry/Irritable Mood 1. Often loses temper. 2. Is often touchy or easily annoyed. 3. Is often angry and resentful. Argumentative/Defiant Behavior 4. Often argues with authority figures or, for children and adolescents, with adults. 5. Often actively defies or refuses to comply with requests from authority figures or with rules. 6. Often deliberately annoys others. 7. Often blames others for his or her mistakes or misbehavior. Vindictiveness 8. Has been spiteful or vindictive at least twice within the past 6 months. |
| panic | Discrete repeated episodes of extreme fear or discomfort, resulting in avoidance/change of activity accompanied by 4 of the following: Shaking or trembling Sweating Shortness of breath Choking sensation Chest pain Racing heart, palpitations, pounding heart Dizziness, feeling faint Tingling or numbness Chills or hot flushes Nausea or upset stomach Feelings of going crazy Feelings of dying, sense of impending doom or terror Derealization |
| ptsd<6 | A. Exposure to actual or threatened death, serious injury, sexual violence: 1 or > 1. Directly experiencing the traumatic event 2. Witnessing, in person, the event as it occurred to others 3. Learning it occurred to a parent or caregiving figure. B. Presence of 1 or > of the following intrusion symptoms: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event. 2. Recurrent distressing dreams 3. Dissociative reactions (flashbacks) in which the child feels or acts as if the traumatic event were recurring. 4. Intense or prolonged psychologic distress at exposure to internal or external cues 5. Marked physiologic reactions to reminders C. 1 or > of the following: either persistent avoidance of stimuli associated with the traumatic event or negative alterations in cognitions and mood associated with the traumatic event, must be present, beginning after the event or worsening after the event: Persistent avoidance of stimuli 1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event 2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event 3. Substantially increased frequency of negative emotional states (fear, guilt, sadness, shame, confusion).4. Markedly diminished interest or participation in significant activities 5. Socially withdrawn behavior. 6. Persistent reduction in expression of positive emotions. D. Marked alterations in arousal and reactivity associated with the traumatic event as evidenced by two (or more) of the following: 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums). 2. Hypervigilance. 3. Exaggerated startle response.4. Problems with concentration. 5. Sleep disturbance F. Duration of the disturbance is more than one month. |
| ptsd>6 | Criterion A: stressor (one required) The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s): Direct exposure Witnessing the trauma Learning that a relative or close friend was exposed to a trauma Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics) Criterion B: intrusion symptoms (one required) The traumatic event is persistently re-experienced in the following way(s): Unwanted upsetting memories Nightmares Flashbacks Emotional distress after exposure to traumatic reminders Physical reactivity after exposure to traumatic reminders Criterion C: avoidance (one required) Avoidance of trauma-related stimuli after the trauma, in the following way(s): Trauma-related thoughts or feelings Trauma-related external reminders Criterion D: negative alterations in cognitions and mood (two required) Negative thoughts or feelings that began or worsened after the trauma, in the following way(s): Inability to recall key features of the trauma Overly negative thoughts and assumptions about oneself or the world Exaggerated blame of self or others for causing the trauma Negative affect Decreased interest in activities Feeling isolated Difficulty experiencing positive affect Criterion E: alterations in arousal and reactivity Trauma-related arousal and reactivity that began or worsened after the trauma, in the following way(s): Irritability or aggression Risky or destructive behavior Hyper-vigilance Heightened startle reaction Difficulty concentrating Difficulty sleeping Criterion F: duration (required) Symptoms last for more than 1 month. |
| riskass | Discussed r/b/se of meds vs no meds. Discussed potential food/drug interactions and s/e of medication. Discussed to call 911 or report to nearest Emergency department for any emergencies. |
| ros | Gen: no fever, fatigue, lethargy GI: no nausea, vomiting, dyspepsia |
| schizo | The presence of 2 (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated), with at least 1 of them being (1), (2), or (3): (1) delusions, (2) hallucinations, (3) disorganized speech, (4) grossly disorganized or catatonic behavior, and (5) negative symptoms. |
| tele | This visit was performed face to face via a secure electronic platform for telemedicine. Patient is located in the state of Oklahoma and patient is off site. Provider is off site. |
| vitals | Vitals obtained off site by patient/parent |