Assessment Master

Assessment & Plan Elements
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NOTE
[checkbox value="First encounter by student|Initial encounter by psychiatric provider|Ongoing treatment by psychiatric provider|Routine followup|discharge planning|family therapy|observation only|shared approach|Student led"]

REFERRAL
[checkbox value="Emergency department|IOP|Partial|Outpatient Psychiatric Appointment|Outpatient Therapy|Primary Care Provider|for inpatient psychiatric hospitalization"]

CURRENT ENCOUNTER HX & CONTENT
[textarea rows="8"]
Patient denies [checkbox value="Suicidal ideation|Homicidal ideation|Self-harm thoughts|Auditory Hallucinations|Visual Hallucinations|Tactile Hallucinations|Difficulty with sleep|Difficulty with appetite|Mood Instability|Adverse effects of medications|Pain/physical complaints"]
Patient reports positive for [checkbox value="Suicidal ideation|Homicidal ideation|Self-harm thoughts|Auditory Hallucinations|Visual Hallucinations|Tactile Hallucinations|Difficulty with sleep|Difficulty with appetite|Mood Instability|Adverse effects of medications|Pain/physical complaints"]
Affect is [checkbox value="flat|blunted|constricted|labile|bright"]
Mood is [checkbox value="anxious|dysphoric|depressed|irritable|tearful|sad|agitated|fearful|euthymic|euphoric"]
Thought process is [checkbox value="Reality based|Disorganized|Circumstantial|tangential|flight of ideas|loose association|perseveration|thought blocking|ideas of reference|grandiose|paranoid|persecutory|religious|somatic|self accusatory"]
Speech is [checkbox value="regular rate and rhythm|rapid|slow|rambling|slurred|monotone|pressured|laconic"]
Gait is [checkbox value="regular|irregular|shuffling|unsteady"]
No observed [checkbox value="psycho-motor agitation|internal preoccupation|response to internal stimuli"]

PAST PSYCH HX
Psychiatric review of systems:
[textarea rows="8"]
Substance/s misuse: [checkbox value="None|Cannabis|Heroin|Prescription Pain medication|Stimulants|Hallucinogens|Cocaine|Alcohol|Tobacco|Caffeine"]
Past psychiatric diagnoses: [checkbox value="None|Depression|Anxiety|ADHD|OCD|PTSD|Oppositional Defiant Disorder|Autism Spectrum Disorder|Bipolar Disorder I|Bipolar Disorder II|Schizophrenia|Schizoaffective disorder|Borderline Personality Disorder|Antisocial Personality Disorder|Mood Disorder"]
Abuse/Trauma: [checkbox value="None|Verbal/Physical abuse as child|sexual abuse|witnessing domestic violence|neglect|bullying|domestic violence|assault|death of a loved one"]
Violence:[checkbox value="None|assaultive to siblings|assaultive to parents|assaultive to staff|unprovoked|as a result of limit setting|when psychotic|resulting in significant injury of victim"]
Legal History/issues: [checkbox value="None|assault charges|protection from abuse order|DHHS involvement|pending court date|probation|to be released into police custody after completion of treatment"]
Suicide/homicide attempts/gestures: [checkbox value="None|overdose|hanging|cutting|walking into traffic|jumping off bridge|threatened life of others"]
Prior Treatment or Therapy inpatient/outpatient: [checkbox value="None|One inpatinet psychiatric hospitalization|multiple inpatient psychiatric hospitalizations|long term state hospital admissions|short term inpatient hospitalizations|crisis unit stays|outpatient psychiatry|outpatient therapy|case management|community support worker|behavior plan in school|school counselor|primary care provider|dental"]
Family/Significant other/social connectedness - family of origin - Patient lives [checkbox value="Alone|not in contact with known family|With parent/s|with parent/s and sibling/s|with other family members|with foster family|with significant other||Has a guardian who is|Mother|Father|Grandparent|DHHS worker|Has payee||Maternal history of:|alcohol use|opiate use|polysubstance use|depression|anxiety|bipolar disorder|schizophrenia|violence|suicide attempts|completed suicide||Paternal History of:|alcohol use|opiate use|polysubstance use|depression|anxiety|bipolar disorder|schizophrenia|violence|suicide attempts|completed suicide||Sibling history of:|alcohol use|opiate use|polysubstance use|depression|anxiety|bipolar disorder|schizophrenia|violence|suicide attempts|completed suicide"]

Hobbies/Acitivities/Habits/Occupation
[textarea rows="2"]

PAST/CURRENT MED HX
[checkbox value="Unremarkable||Cardiovascular history:|Chest pain/angina|CHF|HTN|Hyperlipidemia|cardiac surgeries|DVT||Respiratory history:|asthma|COPD|bronchitis|sleep apnea||Communicable Disease:|Hep A|Hep B|Hep C|HIV/AIDS|TB||Neurological History:|Chronic Pain|Head Injury|Seizure Disorder|Migraine|Chronic headache||Medical Device History:|Bipap/CPAP|Oxygen|Pacemaker|Insulin Pump|Cane|Walker|Dentures|Glasses||Musculoskeletal history:|arthritis|amputation|back/neck problems|congenital abnormalities|fibromyalgia|osteoporosis|metal implants|Endocrine/Metabolic|Diabetes-insulin dependent|diabetes-non-insulin dependent|hypothyroid||Integumentary:|Ulcers|eczema|psoriasis|skin breakdown related to:||EENT history:|ear problems|eye problems|nasal/sinus problems||Sexual/Reproductie history:|Abnormal bleeding/discharge|birth control|menopause|sexually active|sexually transmitted disease|recent pregnancy|currently pregnant"]

LAB WORK:
[checkbox value="Unremarkable"] [checkbox value="Lithium level:"] [textarea memo="0.8-1.2 mEq/L" rows="1"] [checkbox value="Depakote Level:"] [textarea memo="50-110 mcg/mL" rows="1"] [checkbox value="Tegretol Level:"] [textarea memo="5-12 mcg/mL" rows="1"] [checkbox value="Clozapine Level:"] [textarea memo="250-350 ng/mL" rows="1"] [checkbox value="H A1c:"] [textarea memo=">5.7%. 5.7-6.4 = prediabetes" rows="1"] [checkbox value="EKG QTC:"] [textarea memo="360-440 ms" rows="1"] [checkbox value="Ammonia Level:"] [textarea memo="Adults 9.5-49 mcg/dL Child 40-80 mcg/dL" rows="1"] [checkbox value="Prolactin Level:"] [textarea memo="male 2-18ng/mL. female 2-29 ng/mL. pregnant women 10-209ng/mL" rows="1"]

RX HX:
[checkbox value="SSRIs:|Citalopram (Celexa)|Escitalopram (Lexapro)|Paroxetine (Paxil)|Fluoxetine (Prozac)|Fluvoxamine (Luvox)|Sertraline (Zoloft)||SNRIs:|Duloxetine (Cymbalta)|Venlafaxine (Effexor)||Serotonin Antagonists Reuptake Inhibitors:|Trazodone||Norepinephrine Reuptake Inhibitors:|Bupropion (Wellbutrin)|Wellbutrin SR|Wellbutrin XL||Tetracyclic Antidepressants:|Mirtazapine (Remeron)||Serotonin Modulators and Stimulators:|Vilazodone (Viibryd)|Vortioxetine (Trintellix)||Atypical Antipsychotics:|Risperidone (Risperdal)|Olanzapine (Zyprexa)|Quetiapine (Seroquel)|Ziprasidone (Geodon)|Aripiprazole (Abilify)|Paliparidone (Invega)|Lurasidone (latuda)|Clozaril (Clozapine||Typical Antipsychotics|Haloperidol (Haldol)|Chlorpromazine (Thorazine)|Loxapine (Loxitane)|Fluphenazine (Prolixin)|Perphenazine (Trilafon)||Mood Stabalizers|Lithium|Lamotrigine (Lamictal)|Valproic Acid (Depakote)|Carbamazepine (Tegretol)||Anxiolytics:|Clonazepam (Klonopin)|Diazepam (Valium)|Lorazepam (Ativan)|Alprazolam (Xanax)|Hydroxyzine (Vistaril)|Diphenhydramine (Benadryl)|Gabapentin (Neurontin)|Buspirone (Buspar)||ADHD Medications:|Short Acting:|Adderall (Dextroamphetamine Sulf-Saccharate)|Focalin (Dexmethylphenidate)|Vyvanse (Lisdexamfetamine)||Non Stimulant:|clonidine|Kapvay|Guanfacine (Intuniv, Tenex)|Atomoxetine (Straterra)||Intermediate and Long-Acting:|Adderall XR (Dextroamphetamine Sulf-Saccharate)|Focalin XR (Dexmethylophenidate)|MetadateCD/ER (Methylphenidate||Misc:||Folic Acid|Melatonin|Multivitamin|Metoprolol|Propranolol|Clonidine|Lisinopril|Albuterol|"]
[textarea rows="3"]

Current RX:
[textarea rows="8"]

DSM - 5 (ICD - 10 Code) Diagnositics:
The Following are based on currently available info and may be changed as additional info becomes available
[textarea rows="8"]

Applicable Z Codes
[textarea rows="8"]

ENCOUNTER THERAPEUTIC & MEDICAL/MEDICATION MANAGEMENT INTERVENTIONS
Instruments/screening tools, results, & meaning:[textarea rows="1"]
Particular psychotherapeutic strategies used: Person centered therapy, unconditional positive regard, active listening, reflection of feeling.[textarea rows="1"]
Particular medical/medication management strategies:[textarea rows="1"]
Particular psychoeducative strategies:[textarea rows="1"]

DISPOSITION, INSTRUCTIONS, RECOMMENDATIONS, PLAN
[textarea rows="8"]

OWN OBSERVATIONS/IMPRESSIONS
[textarea rows="8"]
NOTE


REFERRAL


CURRENT ENCOUNTER HX & CONTENT

Patient denies
Patient reports positive for
Affect is
Mood is
Thought process is
Speech is
Gait is
No observed

PAST PSYCH HX
Psychiatric review of systems:

Substance/s misuse:
Past psychiatric diagnoses:
Abuse/Trauma:
Violence:
Legal History/issues:
Suicide/homicide attempts/gestures:
Prior Treatment or Therapy inpatient/outpatient:
Family/Significant other/social connectedness - family of origin - Patient lives

Hobbies/Acitivities/Habits/Occupation


PAST/CURRENT MED HX


LAB WORK:
0.8-1.2 mEq/L 50-110 mcg/mL 5-12 mcg/mL 250-350 ng/mL >5.7%. 5.7-6.4 = prediabetes 360-440 ms Adults 9.5-49 mcg/dL Child 40-80 mcg/dL male 2-18ng/mL. female 2-29 ng/mL. pregnant women 10-209ng/mL

RX HX:



Current RX:


DSM - 5 (ICD - 10 Code) Diagnositics:
The Following are based on currently available info and may be changed as additional info becomes available


Applicable Z Codes


ENCOUNTER THERAPEUTIC & MEDICAL/MEDICATION MANAGEMENT INTERVENTIONS
Instruments/screening tools, results, & meaning:
Particular psychotherapeutic strategies used: Person centered therapy, unconditional positive regard, active listening, reflection of feeling.
Particular medical/medication management strategies:
Particular psychoeducative strategies:

DISPOSITION, INSTRUCTIONS, RECOMMENDATIONS, PLAN


OWN OBSERVATIONS/IMPRESSIONS
Result - Copy and paste this output:

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