Psychiatry & Psychology
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PATIENT REPORTED CONCERNS

[checkbox name="Emo_Dis" value="Feeling Emotionally Distressed"][conditional field="Emo_Dis" condition="(Emo_Dis).is('Feeling Emotionally Distressed')"]: [checkbox value="anxiety|depression|anxious and depressed|moody|suicidal ideation|performance anxiety|anger|fear|general distress|worrying|global distress|loneliness|guilt|shame|grief and loss"] [textarea cols=60 rows=5 default="attributed to"] [/conditional]

[checkbox name="Seles" value="Low self-esteem"][conditional field="Seles" condition="(Seles).is('Low self-esteem')"]: [checkbox value="poor self-concept|low self worth|identity diffusion|gender identity concerns|poor self-efficacy|sexual orientation concerns|adoption concerns|feelings of abandonment|poor sense of belonging"] [textarea cols=60 rows=5 default="attributed to"][/conditional]

[checkbox name="Relcon" value="Relationship stress"][conditional field="Relcon" condition="(Relcon).is('Relationship stress')"]: [checkbox value="marital difficulties|friendship problems|fears over impending breakup|recent breakup|social group difficulties|lack of interpersonal effectiveness|poor social supports|family problems|lack of interpersonal coping"] [textarea cols=60 rows=5 default="attributed to"][/conditional]

[checkbox name="Lifetran" value="Life transition stress"][conditional field="Lifetran" condition="(Lifetran).is('Life transition stress')"]: [checkbox value="unable to make life decisions|academic problems|retirement anxiety|moving house anxiety|difficulty with stage of life tasks|leaving home anxiety|leaving high school|poor life satisfaction"] [textarea cols=60 rows=5 default="attributed to"] [/conditional]

[checkbox name="Physcom" value="Physical complaints"][conditional field="Physcom" condition="(Physcom).is('Physical complaints')"]: [checkbox value="eating difficulty|medical problem|injury|physical problems|mobility problems"] [textarea cols=60 rows=5 default="attributed to"][/conditional]

[checkbox name="Subab" value="Substance abuse"][conditional field="Subab" condition="(Subab).is('Substance abuse')"]: [checkbox value="alcohol overuse|substance abuse|substance dependence|spending all available money on addictions|feeling impaired by addiction"] [textarea cols=60 rows=5 default="attributed to"][/conditional]

[checkbox name="Selman" value="Poor Self Management"][conditional field="Selman" condition="(Selman).is('Poor Self Management')"]: [checkbox value="compulsive behaviour|uncontrolled behaviour|phobias|obsessions|thought problems|sexual functioning|uncontrolled feelings|overt behaviour|social behavior|leisure time|leisure activities|procrastination|specific performance|coping skills|making friends|social anxiety|cognitive difficulties"] [textarea cols=60 rows=5 default="attributed to"][/conditional]

[checkbox name="Trau" value="Trauma"][conditional field="Trau" condition="(Trau).is('Trauma')"]: [checkbox value="reported child abuse|recent trauma|ACE|war|victim of crime|injury|accident|unexpected death|unexpected loss"] [textarea cols=60 rows=5 default="attributed to"][/conditional]

[checkbox name="Psychst" value="Psychosocial stresses"][conditional field="Psychst" condition="(Psychst).is('Psychosocial stresses')"]: [checkbox value="poverty|homeless|oppression by others|cultural dislocation|harassment|unemployment|loss of peer group|divorce|separation|job stress|bullying"] [textarea cols=60 rows=5 default="attributed to"][/conditional]

[checkbox name="Ach" value="Lack of Achievement"][conditional field="Ach" condition="(Ach).is('Lack of Achievement')"]: [checkbox value="career|life decisions|academic underachievment|life tasks|life satisfaction|specific performance"] [textarea cols=60 rows=5 default="attributed to"][/conditional]

[checkbox name="Indef" value="Difficult to Define"][conditional field="Indef" condition="(Indef).is('Difficult to Define')"]: [checkbox value="issues which need to be further explored|my troubled past|a variety of pressing concerns|everything seems to be going wrong at this time|has been avoiding problems for years but they're catching up|Not sure, but wants to find out what is bothering me|general life stress|needs to get back into a regular therapy arrangement|want to talk with someone on a regular basis|need someone to talk with about subjects on my mind|seeking psychological support"] [textarea cols=60 rows=5 default="attributed to"][/conditional]

[checkbox name="Qual" value="Quality of life"][conditional field="Qual" condition="(Qual).is('Quality of life')"]: [checkbox value="want to improve the quality of my life|wish to be happy|wanting to see life in new ways"] [textarea cols=60 rows=5 default="attributed to"][/conditional]

PATIENT PROVIDED EXAMPLE OF CURRENT CONCERN

[textarea cols=60 rows=20 default="Patient described"]

NEUROVEGETATIVE CONCERNS

[checkbox value="nil reported|poor sleep|low energy|high energy levels|poor appetite|over-appetite|poor concentration"]

OBSERVATION

-- Appearance and Self-Care --

Pt was [select value="an average height|a small build|a tall build"] [select value="male|female"] [select value="child|adolescent|young adult|adult|older adult"] who looked [select value="average weight|mildly overweight|overweight|obese|mildly underweight|underweight|severely underweight"] for their height. Pt has [select value="fair|tanned|weathered|dark|olive|Mediterranean"] skin with [checkbox value="black|brown|blonde|silver|greying|colourfully dyed|no|red|reddish|platted|straight|frizzy|curly|short|long|shoulder length|tied back|loose|uncombed|unstyled|neatly styled|messy"] hair.

Pt wore [checkbox value="neat|clean|casual|tradie|formal business|expensive casual|inappropriate|meticulously|disheveled|dirty|unwashed|bizarre|stylish|quirky|conservative"] styled clothing. Overall, the Pt's grooming was [select value="unremarkable|meticulous|neglected|bizarre"] with [select value="no|minimal|inappropriate for age|excessive"] cosmetics. Their posture was [select value="relaxed|tense|rigid|stooped|slumped|bizarre"] with [select value="unremarkable|slowed|repetitive|restless|agitated|tremulous"] motor activity.

Other noticeable aspects: [textarea name="field_name" default="Nil"]

-- Sensorium --

Attention: [select value="Unremarkable|Seemed completely unaware|Inattentive|Distractible|Vigilant|Seemed preoccupied with other matters"]
Concentration: [select value="Normal|Scattered|Variable|Preoccupied|Confused|Grossly internalised|Focused 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|angry glaring|None|Staring"]
Facial expression: [select value="Responsive|Constricted|Tense|Anxious|Sad|Depressed|Angry|Blank"]
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/Unremarkable|Mute|Loud|Blocked|Laconic|Pressured|Flight of ideas|Uninteruptable"]
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="Unable to rate|Average|Above average|Impoverished"]
Intellectual functioning: [select value="Average|Below average|Above average|Needs further 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="Easily makes connections|Partial|Occasional|Completely unaware of the problem|In denial"]
Decision making: [select value="Realistic|Simplstic|Impulsive|Vacillates|Confused|Paralyzed|Highly ambivalent"]

-- Current Stressors --

Stressors reported: [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 default="nil"]
Supports needed: [textarea default="No other supports needs at this time"]

-- Social Functioning --

Social maturity: [select value="Responsible|Irresponsible|Self-centered|Childish|Immature|Impulsive|Isolates"]
Social judgment: [select value="Normal|Street smart|Naive|Heedless|Playing the victim|Improper"]

-- Risk --

Suicide: [select value="no active suicidal ideation|Vague suicidal ideation|intense suicidal ideation|Has a suicide plan without intent|Has strong intent to suicide without plan|Has strong intent and a plan to suicide"]

-- Other Aspects of Mental Status --

[textarea default="Nothing to report"]

ASSESSMENT

Diagnostic features: [checkbox value="Nothing of note|Schizophrenia Spectrum|Bipolar Disorder|Depressive Disorder|Anxiety Disorder|OCD|Trauma and Stress related Disorder|Dissociative Disorder|Somatic Symptom related|Feeding and Eating related|Elimination related|Sleep-Wake Disorder|Sexual Dysfunction|Gender Dysphoria|Impulse Control related|Substance related|Neurocognitive Disorder|Medically Induced|Stress|Coping difficulties"]

Personality features: [checkbox value="Paranoid (suspicious)|Schizoid (isolative)|Schizotypal (odd)|Antisocial (hostile)|Borderline (unstable)|Narcissistic (self-interested)|Avoidant (anxious)|Dependent (passive)|Obsessive-compulsive (controlling and rigid)"]

Medical concerns:[checkbox value="Nothing of note|Infection|Neoplasia|Endocrine|Nutritional|Metabolic|Immune system|Haematologic|Neurologic|Circulatory|Respiratory|Digestive|Genitourinary|Pregnancy/childbirth|Dermatological|Musculoskeletal|Connective tissue|Congenital abnormality|Perinatal|Medical problems NOS"]

Psychosocial difficulties: [checkbox value="problems with primary support group|problems related to the social environment|education problems|occupation problems|housing problems|economic problems|problems with access to health care|legal problems|criminal problems|problems related to the environment|no identified concerns"]

Current Overall Functioning: [checkbox value="91 – 100 No symptoms. Superior functioning in a wide range of activities|81 – 90 Absent or minimal symptoms, good functioning in all areas|71 – 80 If symptoms are present, they are transient and expected reactions to psychosocial stressors.|61 – 70 Some mild symptoms, but generally functioning pretty well.|51 – 60 Moderate difficulty in everyday functioning.|41 – 50 Serious impairment in everyday functioning.|31 – 40 Some impairment in reality testing or communication and major impairment in several areas.|21 – 30 Behaviour is considerably influenced by poor reality testing; an inability to function in almost all areas of life.|11 – 20 Some danger of hurting self or others; occasionally fails to maintain minimal personal hygiene; gross impairment in communication.|1 – 10 Persistent danger of severely hurting self or others; persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death.|0 Inadequate information"].

MODIFIABLE FACTORS

[checkbox value="enhance mood|reduce psychotic Sx|decrease eating|increase eating|decrease ETOH|endure withdrawal of substances|distress tolerance|boost hope|improve sleep|tolerate distress|enhance self-efficacy|reduce pain|increase knowledge|increase assertiveness|motivate medical treatment|enhance problem solving|increase resilience|address distorted cognitions|treat medical concerns|medication adherence and compliance|enhance agency|strengthen ego functioning"]

FACTORS IMPACTING ON RECOVERY

[checkbox value="education problems|occupational|housing|debt|economic circumstances|Pt is no psychologically minded|lacking meta-cognitions|very poor insight|difficult social environment|financial stress|over-identifies with sick role|ongoing legal problems|background of childhood adversity|history of victimization|unemployment|problems related to upbringing|medical problems|pregnancy|religious|discord with family|discord with most people|extreme beliefs|personality instability|lifecycle transition|substance misuse|low self-efficacy|sexual difficulties|medication adherence and compliance|psychological defenses|relationship problems|feeling hopeless|unaware of problem|denying the problem"]

STAGE OF CHANGE

[checkbox value="no awareness of the problem|pre-contemplation|is contemplating change|is preparing to change|is taking action to change|is maintaining positive changes"]

PSYCHIATRIC MEDICATION (patient report)

[checkbox value="I haven't been prescribed any medication|I don't want to take it|I'm thinking about it|feels like the dose is too high|feels like the dose is too low|is working as intended|needs to be reviewed with the Dr|is not being taken as suggested|is not working as intended|is having unpleasant side effects|will need a repeat script"]

SUMMARY / IMPRESSION

[textarea cols=60 rows=30 default="Patient presented to me complaining of CONCERNS. Attributed to AXIS 1-4 which has resulted in GAF. Overall, the patient looked and sounded OBSERVATION. Patient is at STAGE OF CHANGE, and improved MODIFIABLE FACTORS would support recovery. However, recovery is complicated by FACTORS IMPACTING ON RECOVERY. Patient is compliant with medication, psychosocial supports and psychological interventions. Progress on their REPORTED CONCERNS is static, fair, good and their recovery could be further enhanced through PLAN"]

PLAN / ACTION

[checkbox value="further assessment|refer to other support services|recommend supportive counselling|recommend insight oriented counselling|recommend CBT|teach and support DBT skills|recommend ACT|recommend psychoeducation|recommend reflective counselling|recommend psychotherapy|recommend behavioural modification|recommend parent training|recommend family therapy|recommend interpersonal effectiveness training|unsuitable for therapy"]

[textarea cols=60 rows=20 default=""]
PATIENT REPORTED CONCERNS

























PATIENT PROVIDED EXAMPLE OF CURRENT CONCERN



NEUROVEGETATIVE CONCERNS



OBSERVATION

-- Appearance and Self-Care --

Pt was who looked for their height. Pt has skin with hair.

Pt wore styled clothing. Overall, the Pt's grooming was with cosmetics. Their posture was with motor activity.

Other noticeable aspects:

-- Sensorium --

Attention:
Concentration:
Orientation Impairment:
Memory Impairment:

-- Relating --

Eye contact:
Facial expression:
Attitude toward author:

-- Affect and Mood --

Affect:
Mood: --
Mood rated out of 10:

-- Thought and Language --

Speech flow:
Thought content:
Thought organisation:
Preoccupations: - Other:
Hallucinations:
Hallucination content:

-- Executive Functions --

Fund of knowledge:
Intellectual functioning:
Abstraction:
Judgment:
Reality testing:
Insight:
Decision making:

-- Current Stressors --

Stressors reported:
Coping ability:
Skill deficits:
Supports: Other:
Supports needed:

-- Social Functioning --

Social maturity:
Social judgment:

-- Risk --

Suicide:

-- Other Aspects of Mental Status --



ASSESSMENT

Diagnostic features:

Personality features:

Medical concerns:

Psychosocial difficulties:

Current Overall Functioning: .

MODIFIABLE FACTORS



FACTORS IMPACTING ON RECOVERY



STAGE OF CHANGE



PSYCHIATRIC MEDICATION (patient report)



SUMMARY / IMPRESSION



PLAN / ACTION



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