CMH – Case Note (normal)

Contact with Pt. [select value="in CMH|via outbound call|via inbound call|at their home|at work|at school|in the community"].

-- Identified Concerns -- 

[textarea cols=70 rows=20 default="No concerns identified"].

-- MSE --  

General: [select value="alert and oriented in all spheres|slowed-lethargic|disoriented"].
Appearance - build: [select value="average|solid|slim|underweight|severely|underweight|overweight|obese"].
Appearance: [select value="well kempt|poorly kempt|appropriately dressed|inappropriately dressed|appropriately groomed|inappropriately groomed|unable to rate"].
Appearance - accessibility: [select value="cooperative|friendly|uncooperative|hostile|alert|confused|hostile|silent|inappropriate boundaries|seductive|playful|ingratiating|evasive|guarded|sullen|manipulative|contemptuous|demanding|withdrawn"].
Appearance - grooming: [select value="Average/WNL|well-groomed|poorly groomed|meticulously groomed|minimal effort|unknown"].
Appearance - clothing: [select value="clean and casual|dirty and ragged|unkempt|neat and casual|tidy|meticulous|formal business attire|worn out|skillfully applied|unconventional|fashionable|unknown|professional|unable to rate"].
Appearance - hygiene: [select value="clean|unbathed|dirty|body odor|smells of alcohol|unknown"].
Psycho-motor activity - posture: [select value="quietly seated|relaxed|stooped|combative|hyperactive|agitated|rigid|stiff|shaky|slouched|bizarre movements|posturing|crouching|erect|restless|unable to rate"].
Behaviour - general: [select value="no apparent distress|mild distress|moderate distress|acute distress"].
Behavior - stability: [select value="calm|agitated"].
Behavior - interactivity: [select value="warm with comments and behavior|interactive but interpersonally cool|withdrawn"].
Behavior - eye contact: [select value="good|fair|avoidant|fleeting|unable to rate"].
Speech - clarity: [select value="clear|slurred|mumbled|lisping|stuttering|inaudible|incoherent|long pauses"].
Mood - stated: [select value="euthymic|upbeat|expansive|euphoric|anxious|flat|depressed|not stated|pt unable to describe"].
Affect - observed: [select value="euthymic|full range of affect|broad|appropriate|constricted|blunted|flat|labile|anhedonic|blunted|emotional withdrawal|excited"]. 
Mood/Affect - intensity: [select value="normal|mild|expansive|blunted|flat"].
Mood/Affect - congruence: [select value="mood congruent with affect|mood and affect are not congruent"].
Thought - form and flow: [select value="logical, relevant, and goal orientated|past orientated|scattered|impoverished|racing thoughts|circumstantial|perservations|flight of ideas|illogical|hopeful|remorseful|enthusiastic|incoherent|neologism|distractable|tangential|overvalued ideas|excited|poverty of though|word salad|clang associations|slow reaction|rapid reaction|doubting|indecisive|blocking|spontaneous|pressured|"].
Attention: [select value="no difficulty with attention or concentration|had some attentional and concentration problems"].
Perception - insight: [select value="normal insight|fair insight|poor insight"]
Thought - perception: [select value="within normal limits|illusions|hallucinations|denationalization|derealization"]
Thought - content: [select value="within normal limits|thought withdrawal|thought insertion|thought broadcast|suspiciousness|grandiose delusions|somatic delusions|delusional guilt|nihilistic delusions|ideas of reference|ideas of inference|magical thinking"].
Cognition/Memory: [select value="normal|grossly intact|below average|above average"].
Cognition/Memory - abstraction: [select value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"]
Judgment: [select value="normal|poor|fair|good"].
Suicidality: [select value="denied current ideation, plan, or intent|disclosed current ideation, but no current plan or intent|disclosed current ideation and plan, but no current intent|disclosed current ideation, plan, and intent"].
Other risks: [textarea cols=50 rows=5 default="No other risks identified"].  

-- Assessment --

[textarea cols=50 rows=20 default=""].

-- Plan --

[textarea cols=50 rows=10 default="No plans made"]