Writer met with patient for follow-up. Pt is a 17-year-old mother of two.

Jane,

These 3 are examples of DAP note. DAP stands for Data, Assessment. They all follow the same format. I have been making up these all quarter and I am running out of creative things to say about patients. Can you make up 12 of these for me? You can give them whatever Dx you want (MDD, Bipolar, Schizo, ADHD, PTSD, etc). Make up any info you want. I will pay you 75

7/20/21 (1)

Data:

Writer met with patient for follow-up. Patient is a 14-year-old female who was diagnosed with Social Anxiety Disorder by Dr. Salim. Pt’s father in active member of the US military. She was born in Germany and spent the first 10 years of her life there. Her family moved to PA in 2019 and she was enrolled in the public school in her township. According to her mother, pt has had difficulty adjusting to her new surroundings since day 1. Patient often pretends to be sick in order to not go to school. Her mother has been called “almost weekly” for issues at school. Patient is not disrespectful to her teachers. Instead, she hides in closest and the girls’ bathrooms during and between classes. She also stopped all sports since moving to the US, because “the girls are very competitive and they scare me”. Pt has not made any friends at school. Pt was started on Lexapro 10mg 4 weeks ago, and patient’s mother has not seen much improvement

Assessment:

Pt short, slim. Alert and oriented x 3. Calm, shy, nervous. No eye contact. Pt gives 1-2 word answers, low volume. No abnormal psychomotor movements. Pt denies SI, HI, AVH, mood swings. Pt rates her anxiety at least 8/10 every time she steps out of the house. She has no ability to concentrate. She sleeps well at night. She is never hungry during the day and usually eats only one meal

Plan:

Increase Lexapro to 20mg daily. Start Buspar 75mg BID. Start Vistaril 25mg Q8H PRN. Follow-up appointment in 2 weeks

7/20/21 (2)

Data:

Writer met with patient for follow-up. Patient has been seen at PPC multiple times. She has a history of noncompliance with her follow-up care and medication regimen. Pt has just been discharged from extended inpatient treatment for drug/alcohol abuse. Pt was introduced to IV heroin at 12-years-old. She has been using almost daily for the past 3 years. Dr. Salim diagnosed patient with Bipolar Disorder Type I and PTSD. Pt stopped taking all of her medications for “probably a year”. While inpatient, she was started on Seroquel 200mg BID, which she has taken in the past with success. She was also started on Minipress 2mg at bedtime, and Prozac 10mg QD. Pt has almost 100 days of sobriety and “I have never felt better”. 

Assessment:

Pt is medium-height, heavy-set. Alert and oriented x 3. Calm, cooperative, friendly. Good eye contact. Speech is non-pressured with normal rate. No abnormal psychomotor movements. Pt denies anxiety, depression, mood swings, SI, HI, AVH. She reports having good energy and the ability to concentrate. She is sleeping 7-8 hours per night.

Plan:

Pt will continue current medication regimen. Follow up in 4 weeks. 

7/20/21 (3)

Data:

Writer met with patient for follow-up. Pt is a 17-year-old mother of two. She lives in a woman’s shelter in Norristown. Patient’s mother cares for her two daughters.  Patient was discharged from Brandywine Hospital 3 days ago, where she was involuntarily admitted after patient was found walking in traffic without clothes during a manic episode. Pt denies using any alcohol or drugs in the past 6 months, but admits that she was not compliant with her medication regimen. She was started on Trileptal 150mg BID. She was also started on Gabapentin and by the time of her discharge was taking 200mg TID. Pt found out from her case manager that the shelter would not accept patients on Gabapentin. According to patient she had to “taper off the medication in 2 days, which was way too fast”.

Assessment:

Pt tall and thin. Alert and oriented x 3. Hyper, anxious, friendly. Poor eye contact. Speech is pressured with fast rate. Patient had to stop multiple times to gather her thoughts. Agitated psychomotor movement in her hands and arms. She reports anxiety 5/10. Denies SI/HI/AVH. Denies mood swings. Pt reports high energy and inability to concentrate. She reports not sleeping well since she was discharged from Brandywine

Plan:

Increase Trileptal to 300mg BID to stabilize mood. Start Buspar 7.5mg BID. Start Melatonin 6mg for bedtime. Follow up in 1 week.

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