M.? 4PM
SUBJECTIVE
MOC states pt is gradually gaining weight but isn't sure why.
Pts stress levels is a 6.5-7; pt thinks she can improve health by increasing sleep.
Pt is currently getting about 2-6 hrs of sleep.
Pt moved to mom’s house one year ago.
Pt takes sleeping tea and Melatonin to around 8:30pm & falls asleep after 11pm.
MOC states that pt is on screen up until pt goes to bed.
Pt has been attending counseling sessions for at least 3 mo, MOC hasn’t seen changes.
Pt spends a lot of time in her room but likes to read, play piano, and draw.
Food:
MOC states pt recently started eating breakfast and pt associates wt gain to this change.
Recent wt gain started a few months ago.
Once a week MOC has to remind pt that snacks are
SUBJECTIVE
MOC states pt is gradually gaining weight but isn't sure why.
Pts stress levels is a 6.5-7; pt thinks she can improve health by increasing sleep.
Pt is currently getting about 2-6 hrs of sleep.
Pt moved to mom’s house one year ago.
Pt takes sleeping tea and Melatonin to around 8:30pm & falls asleep after 11pm.
MOC states that pt is on screen up until pt goes to bed.
Pt has been attending counseling sessions for at least 3 mo, MOC hasn’t seen changes.
Pt spends a lot of time in her room but likes to read, play piano, and draw.
Food:
MOC states pt recently started eating breakfast and pt associates wt gain to this change.
Recent wt gain started a few months ago.
Once a week MOC has to remind pt that snacks are