Psychiatry
Share
Tweet
Cite
Click to rate this SOAPnote
[Total: 0 Average: 0]
approximately 0 views in the 30 days since we checked the card catalog.
ASSESSMENT DETAILS

Date of assessment: [text default="date"]

Time of assessment: [text default="time"]

Communication issues: [textarea cols=50 rows=1 default="Nil communication issues"]

Interpreter required: [textarea cols=20 rows=1 default="No"]

Sources of information: [textarea cols=80 rows=5 default="Patient report; Medical Records; Triage report; Family report; Partner Report; Friend Report"]

Other people present: [textarea cols=40 rows=5 default="Mum, Dad, Caregiver"]

Location: [textarea cols=50 rows=1 default="Community Mental Health"]

Referred by: [textarea cols=50 rows=1 default="Name of referrer"]

Reason for referral: [textarea cols=20 rows=1 default="This patient"] was referred to Community Mental Health for: assessment, treatment, monitoring, care planning, advocacy and linking with rehabilitation and support services.

HISTORY OF PRESENTING PROBLEM

[textarea cols=60 rows=20 default="History"]

Has assessment considered suicidal ideation, preparation or plans: Yes

Has assessment considered risk of harm to others: Yes

Current treatments:

[textarea cols=80 rows=5 default="medications: nil"]
[textarea cols=80 rows=5 default="psychological: nil"]
[textarea cols=80 rows=5 default="complementary / alternative: nil"]
[textarea cols=80 rows=5 default="other services involved: nil"]

Current Physical Health problems:

[textarea cols=80 rows=10 default="details of physical health problems"]

Has assessment considered metabolic risks: Yes

Is the patient a smoker: [select value="Yes|No"]

Current recent substance use:
[checkbox value="None|Cannabis|Heroin|Prescription Pain medication|Stimulants|Hallucinogens|Cocaine|Alcohol|Tobacco|Caffeine"]
[textarea cols=80 rows=10 default="Patient denied substance use when asked"]

Current legal issues:
[textarea cols=80 rows=10 default="Patient denied legal issues when asked"]

Is the patient subject to any legal orders or sanctions: [select value="No|Yes"]

Current functioning and supports:

[textarea cols=80 rows=10 default="Living conditions are currently stable"]

[textarea cols=80 rows=10 default="Relationships are positive; Patient has social supports and denied any recent losses."]

When asked about healthy coping strategies, the patient identified:
[checkbox value="meditation|relaxation|self-care|physical activity|connecting with friends|a sense of humour|hobbies|spirituality|family support|work|meaningful activities|pets|walking|gardening|sleep hygiene|nutrition"] [textarea cols=40 rows=5 default="Nothing of note"]

When asked about unhealthy coping strategies, the patient identified:
[checkbox value="drug use|alcohol use|self-harm|ignoring the problem|sedatives|stimulants|over-work|avoiding the problem|denial|over-sleeping"] [textarea cols=40 rows=5 default="Nothing of note"]

CURRENT PARENTAL/CARER STATUS

Is the patient pregnant or living with someone who is pregnant: [select value="No|Yes"]

Is the patient in an active carer or parental role to dependents: [select value="No|Yes"]

MENTAL STATE EXAMINATION

General: [select value="alert and oriented in all spheres|obtunded|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"].

DV SCREENING

[checkbox value="Yes, within the last year patient name reported being hit, slapped or hurt in other ways by their partner or ex-partner.|No, within the last year patient name denied being hit, slapped or hurt in other ways by their partner or ex-partner.|Yes, patient name is frightened of their partner or ex-partner.|No, patient name is not frightened of their partner or ex-partner."]

DV ACTION TAKEN

[checkbox value="Domestic violence identified, information given.|Domestic violence identified, information refused.|Domestic violence not identified, information refused.|Support given and options discussed.|Reported to FACS.|Police notified.|Other violence/abuse disclosed."]

[textarea cols=80 rows=5 default="DV - referrals made to: N/A"]

[textarea cols=80 rows=5 default="DV - other action taken: N/A"]

[textarea cols=80 rows=5 default="DV - other comments: N/A"]

INVESTIGATION AND RESULTS:

[textarea cols=80 rows=5 default="Pathology results: N/A"]

[textarea cols=80 rows=5 default="Radiology results: N/A"]

[textarea cols=80 rows=5 default="External testing: N/A"]

[textarea cols=80 rows=5 default="Metabolic monitoring: N/A"]

[textarea cols=80 rows=5 default="MH Outcome measures: see forms"]

FORMULATION

[text default="PATIENT"] was referred to our service on [text default="DATE"] to address the follow mental health symptoms: [textarea cols=60 rows=10 default="SYMPTOMS"].

According to [text default="PATIENT"] these symptoms became worse [textarea cols=30 rows=1 default="TIME"], and were likely precipitated in response to [textarea cols=60 rows=10 default="SITUATION"].

On admission, [text default="PATIENT"] rated these mental health symptoms as: [textarea cols=30 rows=1 default="mild, moderate, severe"], and their frequency was described as: [select value="unrelenting|all-day|daily|intermittently during the day|every other day|most days|weekly|some weeks|once a month|occasionally"].

A typical pattern of this dysfunction was described by the Pt as follows: [textarea cols=60 rows=10 default="PATTERN"].

Factors impacting on recovery include: [checkbox value="low motivation to change|denial of the mental health diagnosis|personality factors|poor coping skills|poor rapport with our service|unrealistic expectations for recovery|lack of community based services|difficulty coping with symptoms|unpleasant side effects from medication|poor compliance with medication|missing scheduled appointments|avoiding service contact|not hopefully about the future|unwilling to play an active role in recovery|identifies with the sick role|impulse control difficulties|does not derive benefit from their treatment|social isolation|lack of family support|continual substance abuse|feels stigmatized|engages in splitting behaviours|is hostile towards our service|has a shy and inhibited temperament|poor cohesion between services supporting patient|co-morbid medical problems|has a history of childhood adversity|co-morbid mental health concerns|intellectual difficulties|secondary gains from illness|poor rapport with the case manager"] [textarea cols=80 rows=5 default=""].

As a result, [text default="heshe"] is now struggling to cope with [textarea cols=60 rows=10 default="PROBLEMS"].

Historical factors which may have contributed to this mental health concern include [textarea cols=60 rows=10 default="CONTRIBUTING FACTORS"].

[text default="PATIENT"] was able to identify some positive factors supporting recovery, such as [textarea cols=60 rows=10 default="FACTORS"].

DIAGNOSIS

[textarea cols=80 rows=5 default="Unable to rate"]

IDENTIFICATION OF RISKS

Suicide: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|previous attempt|current ideation, but no current plan or intent|current ideation and has a plan, but no current intent|current ideation, has a plan, and expressed intent"].

Self-harm: [select value="no current ideation or intent|historical self-harm reported|current ideation, but no intent|yes currently self-harms"].

Violence: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|historical violence reported|current ideation, but no current plan or intent|current ideation and has a plan, but no current intent|current ideation, has a plan, and expressed intent"].

Vulnerability: [textarea cols=80 rows=5 default="no foreseeable risks"]

Absconding: [textarea cols=80 rows=5 default="no foreseeable risks"]

Risk to children aged under 18: [textarea cols=80 rows=5 default="no foreseeable risks"]

Other risks: [textarea cols=80 rows=5 default="no foreseeable risks"]

Suicide protective factors: [checkbox value="Treatment responsiveness|Connectedness to others|Problem solving skills|Coping skills|Ability to adapt to change|A sense of purpose or meaning in life|Beliefs that discourage self-injury|Social skills|Anger management|Good health|Access to health care|Fear of risky behaviours and pain|Hope for the future—optimism|Sobriety|Medical compliance|A sense of the importance of health and wellness|Impulse control|Sense of self-worth or self-esteem|Sense of personal control or determination|Access to a variety of clinical interventions|Support for seeking help
|Reasons for living|Married or a parent|Strong relationships with others|Opportunities to participate in and contribute to the world|A reasonably safe and stable environment|Restricted access to lethal means|Responsibilities and duties to others|Pets"].

Factors affecting risk assessment: [checkbox value="Yes, patient name's presentation is highly changeable|No, patient name's presentation is not highly changeable|Yes, patient name's circumstances and supports are stable|No, patient name's circumstances and supports are not stable|Yes, patient name's assessment includes a corroborative history from friends, family and carers|No, patient name's assessment does not include a corroborative history from friends, family and carers|Yes, there are aspects of this assessment that require further clarification|No, there aren't aspects of this assessment that require further clarification."]

IMMEDIATE ACTION PLAN

[textarea cols=80 rows=15 default="Problem / Issue: action planned."]

[textarea cols=80 rows=10 default="Discussed the issues and action plan with patient name and they are in agreement. Date."]

[textarea cols=80 rows=10 default="Discussed the issues and action plan with patient name's carer/parent/guardian and they are in agreement. Date. Additional comments. Contact number"]

[textarea cols=80 rows=10 default="GP is . Contact number. Address"]

[textarea cols=80 rows=10 default="Referrer is . Contact number. Address"]

[textarea cols=80 rows=10 default="Discussed the issues and action plan with team / senior clinician. Date. Additional comments."]

[textarea cols=80 rows=10 default="Additional contacts."]

Modules indicated for further assessment: [checkbox value="Physical|Metabolic|Appearance|Substance|COPMI (children of parents with mental illness|Functional assessment (older adults)|Transcultural|Consumer wellness plan|RUDAS (dementia)"].
ASSESSMENT DETAILS

Date of assessment:

Time of assessment:

Communication issues:

Interpreter required:

Sources of information:

Other people present:

Location:

Referred by:

Reason for referral:was referred to Community Mental Health for: assessment, treatment, monitoring, care planning, advocacy and linking with rehabilitation and support services.

HISTORY OF PRESENTING PROBLEM



Has assessment considered suicidal ideation, preparation or plans: Yes

Has assessment considered risk of harm to others: Yes

Current treatments:






Current Physical Health problems:



Has assessment considered metabolic risks: Yes

Is the patient a smoker:

Current recent substance use:



Current legal issues:


Is the patient subject to any legal orders or sanctions:

Current functioning and supports:





When asked about healthy coping strategies, the patient identified:


When asked about unhealthy coping strategies, the patient identified:


CURRENT PARENTAL/CARER STATUS

Is the patient pregnant or living with someone who is pregnant:

Is the patient in an active carer or parental role to dependents:

MENTAL STATE EXAMINATION

General: .
Appearance - build: .
Appearance: .
Appearance - accessibility: .
Appearance - grooming: .
Appearance - clothing: .
Appearance - hygiene: .
Psycho-motor activity - posture: .
Behaviour - general: .
Behavior - stability: .
Behavior - interactivity: .
Behavior - eye contact: .
Speech - clarity: .
Mood - stated: .
Affect - observed: .
Mood/Affect - intensity: .
Mood/Affect - congruence: .
Thought - form and flow: .
Attention: .
Perception - insight:
Thought - perception:
Thought - content: .
Cognition/Memory: .
Cognition/Memory - abstraction:
Judgment: .
Suicidality: .
Other risks:.

DV SCREENING



DV ACTION TAKEN









INVESTIGATION AND RESULTS:











FORMULATION

was referred to our service on to address the follow mental health symptoms:.

According to these symptoms became worse, and were likely precipitated in response to.

On admission, rated these mental health symptoms as:, and their frequency was described as: .

A typical pattern of this dysfunction was described by the Pt as follows:.

Factors impacting on recovery include: .

As a result, is now struggling to cope with.

Historical factors which may have contributed to this mental health concern include.

was able to identify some positive factors supporting recovery, such as.

DIAGNOSIS



IDENTIFICATION OF RISKS

Suicide: .

Self-harm: .

Violence: .

Vulnerability:

Absconding:

Risk to children aged under 18:

Other risks:

Suicide protective factors: .

Factors affecting risk assessment:

IMMEDIATE ACTION PLAN















Modules indicated for further assessment: .

Result - Copy and paste this output:

Send Feedback for this SOAPnote

Your email address will not be published.

More SOAPnotes by this Author: