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Doctors Note Template 34

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0% found this document useful (0 votes)
109 views2 pages

Doctors Note Template 34

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© © All Rights Reserved
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MEDCARE® Patient Information – GREGORY, D CHRISTOPHER – ID# 342344 - MR# 2834922143

--------------------Patient Copy--------------------

North Texas Infecftious Disease ®


”Assisting You for a Healthy Life…”
-----------------------------------------------
444 NORTH CENTRAL EXPWY DALLAS, TX 75072
PH: 469-222-0293 | FX:480-382-0241

MEDCARE NTID® PATIENT INFORMATION


2nd Floor -MENTAL HEALTH EVALUATION SUMMARY
Patient Information:
Patient ID: 342344 Patient Medical Record Number: 2834922143
Patient Name: GREGORY, D. CHRISTOPHER Patient Address: 801 LINDA CT ALLEN, TX 75002
Responsible Adult: SELF Patient Email: CDUSTIN82@AOL.COM
Patient Weight: 185 LBS Patient Height: 5' 11"
Patient DOB: 05-01-82 Patient Sex: M
Patient Phone Number: 469-900-0348

Visit Information:
Visit Start Date: 3/25/2019 Department: 3rd Floor – psychiatric svcs
Discharge Date/Time: 3/28/2015 12:15:29 PM
Primary Caregiver: Justin Allison, DO Diag: severe depression (medication options
pending)

PATIENT PRESENTS WITH RELATIONSHIP ISSUES AND Anxiety, discussion with patient regarding medication
STATES THAT HE IS CONFUSED AND NOT ABLE TO DISCERN therapy to remedy over period of 2 years and then re-
REALITY evaluate

NO VOICES OR OUTSIDE NOISES EXPERIENCED Patient admits to heavy amphetamine addiction—


NO HALLUCINATION IS PRESENT administration IV >2 gram/day treatment options
NO SELF HARM’/ATTEMPTED SELF HARM *(SELF discussed and alternative solutions will be
DECLARATION) implemented.

PATIENT IS EXPERIENCING STRESS DETERIORATION Patient describes marriage as root of the addiction
COMPOUNDING WITH MANIC DEPRESSIVE ANXIETY AND issues and family history is also showing signs of
PANIC ATTACKS. previous abuse. All proper protocol followed and
patient does not have suicidal tendency/ideations.
IT IS UNCLEAR IF THE PATIENT CAN PERFORM STANDARD
WORK DUTIES AT THIS TIME AND IS ORDERED TO 3 DAY
PSYCHOLOGICAL EVALUATION/INVASIVE MENTAL
ASSESSMENT AND REHABILITATION UNTIL SIGNED OFF ON
BY PRIMARY AS STABLE AND READY FOR DISCHARGE.
TESTING AND ASSESSMENT TO COMMENCE IMMEDIATELY
Other Providers: Dr. Christopher Bettacchi, IMD
Dr. Sujan Schwarma, LADS, MD

Primary Follow-up Info: Please see info below

Discharge Instruction Sheets Provided:


Contact Lifepath systems—mental health one on one therapy 3x a week.
Discuss with support structure the medication options available to treat depression/social anxiety disorders.
Seek out a 12-step program and regularly attend, w/sponsorship and regular scheduling.
No over exertion and/or conflict to immediate well being as ptsd is presentable.

Patient Instructions:
Additional Notes for depressive persons
Return to the ER for new symptoms, worsens or fails to improve.
Additional Notes for seeking care crisis phone and information.
Return to the ER for new symptoms, worsens or fails to continue to improve. Or if thoughts continue to escalate or spiral beyond
patient control.

Follow-up Appointments/Instructions:
Primary Follow-up Information
Continue care opt in to be discussed at next appointment and reevaluation of symptoms vs. medication therapies.

This patient was reviewed by me and should return to me for further consultation no later than
______________________.

©2015 MEDKare, LLC 2/2 3/28/2015 12:00:04

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