I'm happy to share, but my templates are the way I do things, and you probably do it different or better. Right click in the HPI and then type in the box instead. Click Save As New and name it. For instance,
*Telemed
Patient presents via Telemed because of the threat of the Coronavirus pandemic. Patient consents to the possible loss of privacy in being seen this way, and consents to the less than optimal situation for physical exam.
*New Anxiety
CUXOS Anxiety Scale:
(0 = not at all true; 1 = rarely true; to = sometimes true; 3 = often true; 4 = almost always true)
During the PAST WEEK, INCLUDING TODAY:
1. I felt nervous or anxious:
2. I worried a lot that something bad might happen:
3. I worried too much about things:
4. I was jumpy and easily startled by noises:
5. I felt keyed up or on edge:
6. I felt scared:
7. I had muscle tension or muscle aches:
8. I felt jittery:
9. I was short of breath:
10. My heart was pounding or racing:
11. I had cold, clammy hands:
12. I had a dry mouth:
13. I was dizzy or light headed:
14. I felt sick to my stomach (nauseated):
15. I had diarrhea:
16. I had hot flashes or chills:
17. I urinated frequently:
18. I felt a lump in my throat:
19. I was sweating:
20. I had tingling feelings in my fingers or feet:
SCORE:
0-10 not anxious
11-20 minimal anxiety
21-30 mild anxiety
31-40 moderate anxiety
41 and above severe anxiety
(Zimmerman, M., Chelminski, I., McGlinchey, J.B., & Posternak, M.A. A clinically useful depression outcome scale. Comprehensive Psychiatry, 2008, 49, 131-140.)
*ADHD
ADD/ADHD Safety:
Patient presents with complains of difficulty concentrating [AND] impulsive behavior. The historian is a parent.
Parent states he does not have:
heart disease, heart rhythm disorder;
coronary artery disease (hardened arteries); or
history of heart attack;
high blood pressure;
a personal or family history of mental illness, psychotic disorder, bipolar illness, depression, or suicide attempt;
peripheral vascular disease such as Raynaud's syndrome;
epilepsy or other seizure disorder;
tics (muscle twitches) or Tourette's syndrome;
a stomach disorder; or
a history of drug or alcohol addiction.
*Tension HA Episodic
Infrequent, Episodic Tension-Type HA (IHS)
Description:
Infrequent episodes of headache lasting minutes to days. The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity, and it does not worsen with routine physical activity. There is no nausea but photophobia or phonophobia may be present.
Diagnostic criteria:
A. At least 10 episodes occurring on <1 day per month on average (<12 days per year) and fulfilling criteria B-D
B. Headache lasting from 30 minutes to 7 days
C. Headache has at least two of the following characteristics:
1. bilateral location
2. pressing/tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity such as walking or climbing stairs
D. Both of the following:
1. no nausea or vomiting (anorexia may occur)
2. no more than one of photophobia or phonophobia
E. Not attributed to another disorder
