Behavioral

BEHAVIORAL INTERVENTION

Name: [textarea cols=30 rows=1]
DOB: [textarea cols=10 rows=1]
DOS: [textarea cols=10 rows=1]

CONTEXT: [checkbox name="context" value="scheduled phone call with provider|called in||scheduled office visit with provider|scheduled visit for specimen collection|walked in|"][textarea cols=50 rows=3]

LOCATION: [checkbox name="location" value="phone conversation||waiting room|hallway|exam room|"][textarea cols=50 rows=3]

PRESENTS: [checkbox name="presents" value="alone|accompanied by:|"][textarea cols=50 rows=3]

WITNESSED BY: [checkbox name="witness" value="front desk staff|back office staff|manager|interpreter|other patients||provider only||"][textarea cols=50 rows=3]

POTENTIAL TRIGGER: [checkbox name="trigger" value="long wait|new/changing providers|denied medication/accommodation||unknown |"][textarea cols=50 rows=3]

HISTORY: [checkbox name="history" value="reliable historian|supporting documentation available||incomplete history|no information to support authenticity of complaints|"][textarea cols=50 rows=3]

APPEARANCE: [checkbox name="appearance" value="well-appearing|unkempt|bizarre clothes||no signs of pain/discomfort||slumped|appears drowsy/impaired||N/A - phone contract|"][textarea cols=50 rows=3]

VISUAL CONTACT: [checkbox name="visual" value="appropriate|poor|intense staring||N/A - phone contract|"][textarea cols=50 rows=3]

DEMEANOR: [checkbox name="demeanor" value="calm|pleasant||guarded|suspicious|hypervigilant||anxious|fearful|irritable|restless|frustrated||sighing|crying|labile||agitated|forceful|demanding|intense|hostile||euphoric|indifferent|withdrawn|"][textarea cols=50 rows=3]

PSYCHOMOTOR ACTIVITY: [checkbox name="motor" value="no abnormal movements|tics|tremor||bradykinetic||fidgeting|picking, twirling hair|cracking knuckles||grimacing, furrowing eyebrows|breathing hard|raising voice|tightening jaw, grinding teeth|shaking extremities|clenching fists||standing up, pacing|threatening posture/movement|opening door to hallway||N/A - phone contract|"][textarea cols=50 rows=3]

SPEECH: [checkbox name="speech" value="clear & coherent|normal rate & rhythm||hyperverbal|hypoverbal|soft|loud||slow|rapid||slurred|stuttering|monotonous|pressured|perseveration|"][textarea cols=50 rows=3]

VERBAL CONTENT: [checkbox name="verbal" value="repetitive questions|argumentative||insisting on accommodation/disability|insisting on particular medication/test/referral||blaming others|criticisms of staff|staff splitting||cursing, swearing||threats of adverse legal actions|threats of harming office staff/provider|threats of self-harm|"][textarea cols=50 rows=3]

THOUGHT PROCESS: [checkbox name="process" value="organized||circumstantial|tangential|flight of ideas||preoccupation with illness|catastrophization|pessimism|overgeneralization|unrealistic health beliefs|negativism||paranoid ideation/delusions|"][textarea cols=50 rows=3]

INSIGHT: [checkbox name="insight" value="good as evidenced by acknowledging illness and need for treatment|partial as evidenced by acknowledging problem but not need for treatment|poor as evidenced by denial of illness and need for treatment|"][textarea cols=50 rows=3]

SAFETY: [checkbox name="safety" value="no safety concerns||safety concerns d/t impulsiveness|safety concerns d/t hostile temper|safety concerns d/t depressed agitated mood|safety concerns d/t past attempts|safety concerns d/t current SI|"][textarea cols=50 rows=3]

BARRIERS TO CARE: [checkbox name="barrier" value="language barrier|poor effort/cooperation with exam|incomplete history|history not supported by findings|vague shifting complaints||supporting documentation unavailable|failed to obtain old records|failed to complete referrals or testing|| multiple comorbidities|polypharmacy|multiple providers/prescribersIintolerance of/allergty to/therapeutic failure on multiple meds||lack of motivation|dependent attitude|frequent ER/UC visits|frequent office contacts||poor compliance with POC|negative attitude to proposed tx|lack of interest in non-drug tx||overreliance on short-acting meds|overwhelming focus on Rx drugs||alcohol or substance use|psych comorbidity|anxiety|depression||hostile/disruptive behavior|affect||socio-cultural factors||none noted at this time|"][textarea cols=50 rows=3]

ACTION TAKEN: [checkbox name="action" value="provided opportunity to vent feelings|provided treatment alternatives||verbal de-escalation|verbal warning|boundaries/clinic policies reinforced||advised to reschedule visit when better able to focus on health concerns||911 police contacted|attending informed|manager informed|"][textarea cols=50 rows=3]

DISPOSITION: [checkbox name="disposition" value="advised to use ER/UC for acute non-emergent problems||left clinic before visit completion|asked to leave clinic||pt terminated phone call before visit completion|call disconnected||"][textarea cols=50 rows=3]