MH – Brief SOAPNOTE – I
SITUATION 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="mental state monitoring|mental health assessment|psychiatry apt|DEPOT|medication reminder|care coordination|psychotherapy|welfare check|supporting Pt to attend an appointment|sharing clinical formulation|MHRT review"] [text default=""]. Pt expressed concerns with: [checkbox value="nothing in particular|money and finances|debts|life overall|school|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|involuntary status|self-esteem|education|partner|housing|drug use|children|peers|parents"] [textarea cols=60 rows=10 default=""] OBSERVATION Pt is a [checkbox value="male|female"] [checkbox value="young adult|mid-aged adult|older adult|young teen|older teen|child"]. [checkbox value="Reasonably|Not well|Meticiulously"] kempt, looks [checkbox value="average weight|overweight|underweight"]. Posture: [checkbox value="relaxed|rigid|ill-at-ease|stooped|confident|aggressive|tense|slumped|unable to rate"] Movement: [checkbox value="unremarkable|odd / peculiar|slowed|repetitive|restless|agitated|tremorous|unable to rate"] Attention: [checkbox value="no concerns - attended well|seemed unaware|inattentive|distractible|hyper-vigilant|scattered concentration|preoccupied|confused|focused on irrelevancies"] Engagement: [checkbox value="no concerns - warm, chatty, and 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|cold, aloof and inaccessible|manipulative|argumentative"] Mood reported: [text default=""] Affect observed: [checkbox value="mainly euthymic|tearful|labile|restricted|blunted |flat|dysphoric|anxious|angry |apathetic|ashamed|prideful|sad|irritable|hostile|pessimistic|depressed|manic|euphoric|unable to rate"] 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|mute - unable to rate"] 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)|unable to rate"] Orientation: [checkbox value="no concerns|AH reported|VH reported|poor judgement|poor reality testing|poor insight|complete denial|unable to rate"] Stressors disclosed without prompting: [checkbox value="nil|self-esteem|parenting|mental illness Sx|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"] 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|unable to rate"]. ASSESSMENT Impression of current mental health symptoms: [checkbox value="stable|improved|worsening|unable to rate"] [textarea default="Service contact with Pt for (SITUATION) complete."] PLAN [checkbox value="will see Pt at their next scheduled apt|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|dvised 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|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=""] Risk: [checkbox value="No need for further action today|I reminded the patient to call the Acute Care Service if needed, present to CMH during business hours, present to the ED after hours, or call emergency services 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 made a notification of concerns to social services|I reported concerns of violence to the police|I refered Pt to Accute Care Team for after hours followup"] Next apt [textarea cols=30 rows=1 default=""]
There are 29 form elements.