Efficiency App

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Admission

ProcedureCode

Carrier Rate

Visit Units

Total Value

Notes Orders Created

Notes for Review

DateOfService

Follow Up Date

Clear

Physical Restraint

Physical Restraint Date

Clear

Physical Restraint Time

Physical Restraint Nurse

Physical Restraint Reason

Physical Seclusion

Physical Seclusion Date

Clear

Physical Seclusion Time

Physical Seclusion Nurse

Physical Seclusion Reason

PlaceOfService

Modifier1

Charges

Chart History

History

Current Medications

Radiology Results

Formulation

Formulation Precipitating Factors

Formulation Aggravating Factors

Formulation Maintaining Factors

Medication Options

Action

Medication

Dose

Route

Frequency

Add

Status

Last Administration Date

Next Administration Date

Pharmacist

Reason

Comments

Action	Medication	Dose	Route	Frequency	Status	Last Administration Date	Next Administration Date	Pharmacist	Reason	Comments

PRN Received

Medication Name

Medication Route

Medication Dose

Nurse

Date

Time

Reason

	Medication Name	Medication Route	Medication Dose	Nurse	Date	Time	Reason

Medication Plan

Nursing Communications

Social Worker Cummunications

Lab Orders

Precautions

Short Term Goals

Long Term Goals

Level of observation

Level of Observation Reason

Chart Hx

Inpatient Status

Scales

Medication Review

Labs Ordered

Visited

Medication notes

Interventions

VisitSubmitted

ReuseIPE

Vs weight

Vs height

Vs temperature

Vs respirations

Vs pulse

Vs blood pressure

Vs date drawn

Reliability

UpdatedDate

Inpatient Certificate Uploaded

Inpatient Certificate Uploaded Date Time

Inpatient Certificate Uploaded User

Master Treatment Plan Uploaded

Master Treatment Plan Date Time

Master Treatment Plan User

Xray Conclusion

Level of risk of dangerousness violence to self

Suicide risk

Level of risk of dangerous violence to others

Violence risk

Psychotherapy

Time spent in session face to face during patient visit

Observations

Observations Medications

Call Center Observations

Restricted rights physical hold

Restricted rights restraint

Restricted rights seclusion

Restricted rights administered emergency medication

Restricted rights individual indicated no preference emergency

Restricted rights individual preference was utilized

Restricted rights individual preference reasons

Restricted rights refuse x ray

Restricted rights refuse medical services laboratory

Restricted rights retain personal property

Restricted rights refuse other medical services

Restricted rights refuse search person

Restricted rights refuse other

Restricted rights allowed communication telephone

Restricted rights allowed communication mail

Restricted rights allowed communication visitation

Restricted rights allowed communication other

Restricted rights identified restrictions reasons

Restricted rights copy english

Restricted rights copy other

Restricted rights indiviudal wished notified

Restricted rights indiviudal guardian notified

Restricted rights indiviudal guardian address

Restricted rights indiviudal designee notified

Restricted rights indiviudal designee address

Letter

Transcripts

Cases management

Consent Sign

Reason for referral

What issues would report clarify

Updated information benefit patient

Location administration test

Time administer patient

Defense Mechanisms Primitive

Defense Mechanisms Intermediate

Defense Mechanisms Mature

EGO Functioning Reality

EGO Functioning understand concept self

EGO Functioning victim narrative

EGO Functioning physical objects

EGO Functioning digital objects

EGO Functioning masculine feminine energy

Networks Dopamine

Networks Nor Epinephrine

Networks Serotonin

Networks Acetylcholine

Networks GABA

Networks Glutamate

Physical Exam

Physical exam constitutional general

Physical exam constitutional appearence

Physical exam hent head

Physical exam eyes general

Physical exam eyes pupuls

Physical exam cardiovascular rate and rhythm

Physical exam cardiovascular heart sounds

Physical exam pulmnoary effort

Physical exam pulmnoary breath sounds

Physical exam abdominal general

Physical exam abdominal palpations

Physical exam abdominal tenderness

Physical exam musculoskeletal cervical back

Physical exam lymphadenopathy cervical

Physical exam skin general

Physical exam skin capillary refill

Physical exam skin findings

Physical exam neurological mental status

Physical exam neurological motor

Physical exam neurological coordinator

EKG

Ekg qtc

Ekg qtc interval

Ekg condition

Ekg date drawn

BMP

Bmp sodium

Bmp potassium

Bmp chloride

Bmp carbon dioxide

Bmp bun

Bmp creatinine

Bmp glucose

Bmp date drawn

CBC

Cbc wbc

Cbc hgb

Cbc hct

Cbc plt

Cbc date drawn

LABS

Labs

Labs valproic acid date drawn

Labs valproic acid

Labs lithium date drawn

Labs lithium

Labs tegretol date drawn

Labs tegretol

Labs liver function test date drawn

Labs ast

Labs alt

Labs ggt

Labs ethanol date drawn

Labs ethanol

Labs EKG results

Labs hcg urine date drawn

Labs hcg urine

Labs hcg blood date drawn

Labs hcg blood

Urine Drug Screen

Labs urine drug screen date drawn

Labs cocaine

Labs marijuana

Labs opioids

Labs PCP

Labs benzodiazepines

Labs amphetamines

Labs barbiturates

MSE

MSE TEMPLATES

MSE

Mse general appearance

Mse attitude behavior

Mse affect

Mse mood

Mse speech quantity

Mse speech rate

Mse speech volume

Mse speech rhythm

Mse thought process

Mse thought content

Mse suicidal ideations

Mse suicidal ideations describe

Mse homicidal ideations

Mse homicidal ideations describe

Mse hallucinations

Mse orientation

Mse attention span

Mse attention span test

Mse recent memory

Mse recent memory test

Mse remote memory

Mse remote memory test

Mse abstract reasoning

Mse abstract reasoning test

Mse intelligence

Mse intelligence test

Mse judgment

Mse judgment test

Mse insight

Mse insight test

ROS

ROS Cardiovascular

ROS Allergic Immunologic

ROS Constitutional

ROS Head ears eyes nose and throat

ROS Endocrine

ROS Eyes

ROS Gastrointestinal

ROS Genitourinary

ROS Hematologic Lymphatic

ROS Integumentary

ROS Musculoskeletal

ROS Neurological

ROS Psychiatric

ROS Respiratory

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