Brief Clinical Note – III

Psychiatry & Psychology
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Contact with [checkbox value="Pt|Pt's NDIS worker|Pt's NGO case-worker|Pt's parent|Pt's GP"] [text default=""], [checkbox value="at Pt's home|in Community Mental Health|via telephone|via SMS|via email|via fax|via post"] [text default=""], for the purpose of [checkbox value="a mental state evaluation|DEPOT|medication reminder|care coordination|psychotherapy|welfare check|supporting Pt to attend an appointment|sharing clinical formulation|MHRT review"] [text default=""].

SUBJECTIVE REPORT

When asked about Pt's current overall mental state, the [checkbox value="Pt|Pt's NDIS worker|Pt's NGO case-worker|Pt's parent|Pt's GP"] [text default=""] reported [checkbox value="he is|she is|they are"][checkbox value="ok generally|fine|sad|concerned|annoyed|anxious|depressed|enthusiastic|confused|distracted|lonely|desperate|happy|relieved|indifferent|good|surprised|self-conscious|guilty|disgusted"][text default=""]. When asked about areas of current concern, the [checkbox value="Pt|Pt's NDIS worker|Pt's NGO case-worker|Pt's parent|Pt's GP"] [text default=""] reported: [checkbox name="variable_1" value="nothing in particular|money and finances|debts|life overall|physical health|unpleasant thoughts|relationship|mental health overall|job|employment|family|body|eating|weight|neighbours|support workers|medication|sleep|unpleasant memories|lack of role|friendships|legal problems|status as a Pt|self-esteem|education|partner|housing|drug use|children|peers|parents"][text default=""], stating: [textarea default=""].

OBSERVATIONS

Pt is a [checkbox value="young adult|mid-aged adult|older adult|young teen|older teen|child"] [checkbox value="male|female"]. [checkbox value="Reasonably|Not well|Meticiulously"] kempt [checkbox value="+|++|+++"], [checkbox value="average weight|overweight|underweight"][checkbox value="+|++|+++"].
Posture [checkbox value="relaxed|rigid|stooped|confident|aggressive|tense|slumped"][checkbox value="+|++|+++"]
Movement [checkbox value="unremarkable|odd / peculiar|slowed|repetitive|restless|agitated|tremorous"][checkbox value="+|++|+++"]
Attention: [checkbox value="no concerns - attended well|seemed unaware|inattentive|distractible|hyper-vigilant|scattered concentration|preoccupied|confused|focused on irrelevancies"][checkbox value="+|++|+++"]
Engagement: [checkbox value="no concerns - engaged well|avoided eye contact|fixed staring|glaring at author|tense facial expression|dependent and needy|dramatic and exaggerating concerns|passive and difficult to engage|uninterested|silly and joking around|resistant|critical and verbally combative|hostile and threatening|sarcastic and taunting|irritable|fatuous|flirtatious|demanding|threatening|guarded|paranoid|defensive and resistant|manipulative|argumentative"][checkbox value="+|++|+++"]
Mood reported & affect observed: [checkbox value="euthymic|tearful|labile affect|restricted affect|blunted affect|flat affect|dysphoric|anxious|angry |apathetic|ashamed|prideful|sad|irritable|hostile|pessimistic|depressed|manic|euphoric|neutral"][checkbox value="+|++|+++"]
Speech: [checkbox value="spontaneous|normal RTV|abnormal RTV|clear and articulate|selectively mute|mute|loud|laconic|verbose|quiet|pressured|rambling|babbling|incongruent with mood and current circumstances"][checkbox value="+|++|+++"]
Thinking: [checkbox value="logical|linear|rigid and concrete|personalizing|persecutory|indecisive|unrealistic|difficulties of reference|magical ideas of influence|distorted|pseudologica fantastica|memory difficulties|provided unnecessary detail (circumstantial)|wandered between many topics (tangential)|jumped from one idea to another (loose associations)|racing thoughts (flight of ideas)|abruptly changed topic or stopped mid-sentence (thought blocking)|tended to loop or repeat themes (obsessive)|stuck on over-valued ideas (preoccupations)"][checkbox value="+|++|+++"]
Orientation: [checkbox value="no concerns|AH reported|VH reported|poor judgement|poor reality testing|poor insight|complete denial"][checkbox value="+|++|+++"]
Stressors disclosed without prompting: [checkbox value="nil|self-esteem|parenting|spouse|money|school|physical health|energy|sleep|body weight\shape|eating|food|housing|employment|mood|family|work|grief and loss|illness|transitions|legal|peers|relationship"][checkbox value="+|++|+++"]
Suicide risk: [select value="denied active suicidal ideation when asked|vague suicidal ideation|intense suicidal ideation|has a suicide plan without strong intent|has strong intent to suicide without a plan|has strong intent and a plan to complete suicide"].

ASSESSMENT

Overall progress since last contact: [checkbox value="improved|fair|static|worsening|unable to rate"].
Impression of current mental health Symptoms: [checkbox value="stable|improved|worsening|unable to rate"][checkbox value="+|++|+++"]. [checkbox value="Pt is functioning well overall, no urgent action needed.|Although Pt functions poorly in certain domains, they are mentally stable and likely operating at their current baseline.|Pt is struggling as a result of their mental health Sx. No urgent concerns, but I have offered extra support.|Pt is functioning poorly and requires extra support.|Pt is in an acute phase of their illness and needs to be reviewed urgently.|Pt is in breach of their CTO requirements and will require a breach notification."]

[textarea default="other details"]

ACTION

[checkbox value="advised to contact me if concerns arise, and will contact Pt before our next scheduled apt|arranged a psychiatric review and provided apt details|contacted police to express my urgent concerns|provided details about the Pts next apt with me|urged Pt to see their GP|arranged for medication support|arranged for Pt to have their DEPOT|offered supportive counselling|deescalated their emotional distress|escorted Pt to the ED|contacted the Pts housing provider"], [comment memo="add a specific action"] [textarea default=""]

RISK ASSESSMENT

[checkbox value="No need for further action today|I reminded the patient of their calling MHAL 1800011511 if needed, and urged them to present to the ED or call 000 in a crisis|Pt and I agreed to a harm minimization approach by removing access to lethal means|and I further discussed their risks with their parent|I called emergency services and reported my concerns|I called the MHAL and reported my concerns|I made a notification of suspected abuse to FACS|I reported concerns of violence to the police|I will refer Pt to ACS for followup"]

PLAN

[checkbox value="will evaluate Pt in a month or so|book a psychiatry review|home visit for welfare check|will see Pt at their next psychiatry review or DEPOT|contact their GP|arrange a medical admission|arrange a psychiatric admission|arrange NGO support|arrange CTO hearing and paperwork|will monitor their symptoms with weekly contacts|alert their partner and family about current concerns|update their risk assessment|will review Pt at next MDT|refer Pt to the acute mental health team for followup|refer Pt to D&A services|contact and alert police|issue Pt with breach of CTO conditions|get Pt's scripts to pharmacy"] [textarea default=""]

NEXT APT

[textarea default="to be planned"]
Contact with , , for the purpose of .

SUBJECTIVE REPORT

When asked about Pt's current overall mental state, the reported . When asked about areas of current concern, the reported: , stating:.

OBSERVATIONS

Pt is a . kempt , .
Posture
Movement
Attention:
Engagement:
Mood reported & affect observed:
Speech:
Thinking:
Orientation:
Stressors disclosed without prompting:
Suicide risk: .

ASSESSMENT

Overall progress since last contact: .
Impression of current mental health Symptoms: .



ACTION

, add a specific action

RISK ASSESSMENT



PLAN



NEXT APT

Result - Copy and paste this output:

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