Case Management Appointment
Writer [select name="duh" value="met face-to-face with|met via Zoom with|called|emailed|had text (SMS) exchange with"][select name="Who" value="client|parent|family|MHCC|social worker"] to [select name="dooo" value="conduct case management|schedule services|conduct family session|conduct parent session|conduct individual/parent session|request_____"]. When asked to rate how things have been over the last week, client reported that [select name="Q1" value="things have been unremarkable.|there have been some difficulties.|life has been pretty good.|"][conditional field="Q1" condition="(Q1).is('there have been some difficulties.')"] When asked to elaborate, client reported concerns with: [conditional field="Q1" condition="(Q1).is('there have been some difficulties.')"][checkbox name="lastweek" value="the primary support group|the social environment|education|work|housing|finances|access to health care services|legal justice system|psycho-social functioning and their environment"].[/conditional] [textarea cols=80 rows=5 default="additional comments"] Client reported [select name="test" value="one|two|three|four|five|six|seven|eight|nine|ten"] hours of [select value="good|fair|poor|terrible"] sleep a night. Client rated appetite as [select value="good|fair|poor|terrible"], and reported eating [select value="every other day|once per day|twice per day|three times per day"] with [select value="easy|moderate|hard|no"] access to food. Client reported that overall mood is [text name="variable_1" default="sample text"] Client reported [select name="variable_1" value="no issues|issues"] with medication and taking it [select name="variable_1" value="as prescribed|not as prescribed"]. Client reported [select name="SI/HI" value="no active|active|"] SI/HI. [conditional field="SI/HI" condition="(SI/HI).is('active')"] ggggggg [/conditional] Has a suicide plan] without intent|Has strong intent to suicide without plan|Has strong intent and a plan to suicide"] Client reported _no/some/current_ thoughts of SI/HI. Client reported __issues/no issues___ with medication and taking it ____compliently/noncompliently. Client reported that appetite is_____ and eating ____ a day with _____easy/moderate/hard____ access to food. Client reports their housing as _______ Stable/unstable with__no/some/immident____threat of homelessness. Client reported ____no/some/many___ issues with hygiene. Client reported showering ____ times a _____. Client reported a _______ homelife. Client reported no substance use. MENTAL STATUS EXAMINATION -- Appearance and Self-Care -- Stature: [select value="Average|Small|Tall"] Weight: [select value="Average weight|Overweight|Obese|Underweight"] - Weight [text name="field_name" default="not assessed"] Clothing: [select value="Neat/clean|Careless|Inappropriate|Meticulous|Disheveled Dirty|Bizarre"] Grooming: [select value="Unremarkable|Meticulous|Neglected|Bizarre"] Cosmetics: [select value="Unremarkable|Inappropriate for age|Excessive|None"] Posture: [select value="Normal|Tense|Rigid|Stooped|Slumped|Bizarre"] Motor activity: [select value="Unremarkable|Slowed|Repetitive|Restless|Agitated|Tremor"] Other noticeable aspects: [textarea name="field_name" default="Nil"] -- Sensorium -- Attention: [select value="Normal|Unaware|Inattentive|Distractible|Vigilant"] Concentration: [select value="Normal|Scattered|Variable|Preoccupied|Confused|Anxiety interferes|Focuses on irrelevancies"] Orientation Impairment: [checkbox name="Orientation" value="Nil|Time|Person|Place|Situation|Object"] Memory Impairment: [checkbox name="MemImp" value="Nil|Working memory|Short term|Recent|Remote|Particular events|Confabulates|Amnesiac"] -- Relating -- Eye contact: [select value="Normal|Fleeting|Avoidant|None|Staring"] Facial expression: [select value="Responsive|Constricted|Tense|Anxious|Sad|Depressed|Angry"] Attitude toward author: [select value="Cooperative|Dependent|Dramatic|Passive|Uninterested|Silly|Resistant|Critical|Hostile|Sarcastic|Irritable|Threatening|Suspicious|Guarded|Defensive|Manipulative|Argumentative"] -- Affect and Mood -- Affect: [select value="Appropriate|Labile|Restricted|Blunted|Flat"] Mood: [select value="Euthymic|Anxious|Angry|Apathy|Ashamed|Prideful|Sad|Irritable|Hostile|Pessimistic|Depressed|Hypomanic|Euphoric"] -- [text name="field_name" default="other"] Mood rated out of 10: [select value="Not rated|1|2|3|4|5|6|7|8|9|10"] -- Thought and Language -- Speech flow: [select value="Normal|Mute|Loud|Blocked|Paucity|Pressured|Flight of ideas"] Thought content: [select value="Congruent with mood and circumstances|Incongruent Congruent with mood and circumstances|Personalizations|Persecutions|Indecisions|Suspicions|Delusions|Ideas of reference|Ideas of influence|Illusions"] Thought organisation: [select value="logical and goal directed|Circumstantial|Tangential|Loose associations|Flight of ideas|Neologisms|Blocking|Obsessive"] Preoccupations: [select value="Nil|Phobias|Somatic|Suicide|Homicidal|Guilt|Religion"] - Other: [text name="field_name" default="Nil"] Hallucinations: [select value="Nil|Auditory|Visual"] Hallucination content: [text name="HalCon" default="N/A"] -- Executive Functions -- Fund of knowledge: [select value="Average|Above average|Impoverished"] Intellectual functioning: [select value="Average|Below average|Above average|Needs Assessment"] Abstraction: [select value="Normal|Concrete|Functional|Popular|Abstract|Overly abstract"] Judgment: [select value="Sound|Fair|Poor|Dangerous"] Reality testing: [select value="Realistic|Adequate|Distorted|Variable|Unaware"] Insight: [select value="Makes connections|Gaps|Occasional|Unaware|Nil|In denial"] Decision making: [select value="Normal|Simplstic|Impulsive|Vacillates|Confused|Paralyzed"] -- Current Stressors -- Stressors: [checkbox name="Stressors" value="Money|Housing|Family conflict|Work|Grief and loss|Illness|Transitions|Legal difficulties|Peer group|Relationship"] Coping ability: [select value="Normal|Resilient|Exhausted|Overwhelmed|Deficient supports"] Skill deficits: [checkbox name="SkillDefs" value="None|Education|Communication|Interpersonal|Decision making|Self control|Responsibility|Self care|Activities of daily living"] Supports: [checkbox name="Supports" value="Self|Family|Friends|Parole officer|Church|NGO|GP"] Other: [text name="field_name" default="Other supports"] Supports needed: [textarea name="field_name" default="No other supports needs at this time"] -- Social Functioning -- Social maturity: [select value="Responsible|Irresponsible|Self-centered|Impulsive|Isolates"] Social judgment: [select value="Normal|Street smart|Naive|Heedless|Victimized|Improper"] -- Risk -- Suicide: -- Other Aspects of Mental Status -- [textarea name="field_name" default="Nothing to report"] PRESENTING CONCERNS 1: [textarea cols=60 rows=1 default=""] Patient reported: [textarea cols=60 rows=10 default=""] Impression: [textarea cols=60 rows=10 default=""] Plan: [textarea cols=60 rows=10 default=""] 2: [textarea cols=60 rows=1 default=""] Patient reported: [textarea cols=60 rows=10 default=""] Impression: [textarea cols=60 rows=10 default=""] Plan: [textarea cols=60 rows=10 default=""] 3: [textarea cols=60 rows=1 default=""] Patient reported : [textarea cols=60 rows=10 default=""] Impression: [textarea cols=60 rows=10 default=""] Plan: [textarea cols=60 rows=10 default=""] 4: [textarea cols=60 rows=1 default=""] Patient reported : [textarea cols=60 rows=10 default=""] Impression: [textarea cols=60 rows=10 default=""] Plan: [textarea cols=60 rows=10 default=""] 5: [textarea cols=60 rows=1 default=""] Patient reported : [textarea cols=60 rows=10 default=""] Impression: [textarea cols=60 rows=10 default=""] Plan: [textarea cols=60 rows=10 default=""] 6: [textarea cols=60 rows=1 default=""] Patient reported : [textarea cols=60 rows=10 default=""] Impression: [textarea cols=60 rows=10 default=""] Plan: [textarea cols=60 rows=10 default=""] 7: [textarea cols=60 rows=1 default=""] Patient reported : [textarea cols=60 rows=10 default=""] Impression: [textarea cols=60 rows=10 default=""] Plan: [textarea cols=60 rows=10 default=""] 8: [textarea cols=60 rows=1 default=""] Patient reported : [textarea cols=60 rows=10 default=""] Impression: [textarea cols=60 rows=10 default=""] Plan: [textarea cols=60 rows=10 default=""] 9: [textarea cols=60 rows=1 default=""] Patient reported : [textarea cols=60 rows=10 default=""] Impression: [textarea cols=60 rows=10 default=""] Plan: [textarea cols=60 rows=10 default=""] Next appointment: [textarea cols=50 rows=1 default="has not been arranged"]
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Sandbox Metrics: Structured Data Index 0.51, 98 form elements, 303 boilerplate words, 6 text boxes, 41 text areas, 6 checkboxes, 42 drop downs, 3 conditionals, 138 total clicks
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