CMH – Discharge / Transfer

VISIT INFORMATION

Dear Colleague,

Thank you for continuing the care of [text name default=""] who was recently discharged from Community Mental Health. I am writing to update you on [text name default="his her"] mental health status and current functioning.

On the [textarea cols=40 rows=1 default="date"], [text name default="NAME"] was admitted to our service, and was assessed as experiencing the symptoms associated with: [textarea cols=80 rows=4 default="diagnosis"]. [link url="http://apps.who.int/classifications/icd10/browse/2010/en#/V" memo="ICD-10 diagnoses"]

Other concerns identified at initial assessment:

Our assessment also revealed significant difficulties with: [checkbox value="symptoms associated with a mental illness|intrusive negative thoughts|physical illness|death of friend|death in the family|death of a partner|coping with poor health|coping with partners poor health|adjusting to stage of life|withdrawing from substances|personal upheaval|divorce|separation from partner|relationship problems|imprisonment|poverty|personal injury|marrital discord|dismissal from work|marital reconciliation|retirement|change in health of a family member|pregnancy|sexual difficulties|gain a new family member|business readjustment|change in financial status|arguments with others|mortgage|debt|work stress|child leaving home|trouble with in-laws|lack of achievement|partner's employment status|school starting|school ending|change in living conditions|revision of personal habits|trouble with the boss|trouble with parents|change in work hours|change in work conditions|change in residence|change in school|church|religion|change in social activities|money worries|change in sleep habits|change in family structure|change in eating habits|vacation|Holiday stress|legal problems|problems with the weather|academic underachievement|target of bullying|discord with teachers|stressful work schedule|under-employment|hazardous work conditions|exposure to toxins|inadequate housing|homelessness|discord with lodgers|discord with neighbours|discord with landlord|insufficient welfare support|low self-esteem|physical abuse|sexual abuse|emotional abuse|a traumatic experience|parental pressure|unusual parenting practices|discord with healthcare professional|legal problems|victim of crime|immigrant status|minority status|marginalisation|social withdrawal and isolation|unable to make friends"][textarea cols=80 rows=10 default="no other problems reported"].

As a patient of Community Mental Health, [text name default="NAME"] was provided with [checkbox value="Psychiatric Assessment|1:1 Psychotherapy|Family-Based therapy|Pharmacological treatment|Psycho-education|Community support services|Psychological Assessment|and numbers to call during a relapse crisis"]. 

Clinical Global Impression:

On discharge, the severity of [textarea cols=40 rows=1 default="diagnosis"] was assessed as: [select name="severity" value="normal, not at all ill|almost fully recovered|mildly ill|moderately ill|markedly ill|severely ill|among the most extremely ill patients"]; and compared to the patient's condition on admission, I rate their improvement as: [select name="improvement" value="very much improved|much improved|minimally improved|no change|minimally worse|much worse|very much worse|unable to be assessed"].

Risk Assessment on Discharge:

Suicide: [select name="Suicide" value="Low risk|No (foreseeable) risk|Medium risk|High risk"]
Self-Harm: [select name="Self-harm" value="Low risk|No (foreseeable) risk|Medium risk|High risk"]
Violence: [select name="Violence" value="Low risk|No (foreeseeable) risk|Medium risk|High risk"]
Vulnerability: [select name="Vulnerability" value="Low risk|No (forseeable) risk|Medium risk|High risk"]
Absconding: [select name="Absconding" value="Low risk|No (foreseeable) risk|Medium risk|High risk"]
Other: [select name="Other" value="Low risk|No (foreseeable) risk|Medium risk|High risk"]

Medications: [textarea cols=80 rows=40 default=""].
 
Discharge plan: [checkbox value="provided patient name the details of the expected time and date of discharge|established carer’s capability and willingness to assist|arranged for sufficient quantities of medication to last until the next consultation|checked that the patient understands the purpose, dosage, frequency and side-effects of their medication|discussed the expected recovery path and confirmed understanding|confirmed necessary follow-up appointments with the patient's healthcare provider|arranged travel assistance|provided details of the patient's medical follow-up appointments|provided contact details for community mental health services and follow up arrangements|provided contact details for private mental health services and follow up arrangements|educated the patient about signs of possible relapse and what to do|provided the patient with emergency contact numbers|provided the patient with a self-management plan (including coping strategies)|provided the patient with a crisis management plan|confirmed community support arrangements including referrals to other services / programs"].

Kind Regards,


Clinican Name
Clinical Tilte
Community Mental Health
Tel: [text name default=""]
 
-- Summary of Care --
[textarea cols=30 rows=1 default="patient name"] was provided with: [checkbox value="a mental health triage assessment|a psychiatric assessment|a psychological assessment|1:1 psychotherapy|family-based therapy|medication|mental health education|a referral to community support services|case-management|supportive counselling"]. 

HEALTH STATUS

-- Clinical Impression -- 

FORMULATION

[text default="PATIENT"] presented to me on [text default="DATE"] complaining of [textarea cols=60 rows=10 default="SYMPTOM LIST"]. According to [text default="PATIENT"] these concerns became worse about [text default="DATE"], and were likely precipitated by [textarea cols=60 rows=10 default="PRECIPITATING EVENT"]. As a result, [text default="heshe"] is now struggling to cope with [textarea cols=60 rows=10 default="PROBLEM LIST"]. Historical factors which may have contributed to this current concern include [textarea cols=60 rows=10 default="FACTORS"]. [text default="PATIENT"] was able to identify some positive factors supporting recovery, such as [textarea cols=60 rows=10 default="FACTORS"].

-- Identification of Risks --

Suicide: [select name="Suicide" value="Low risk|No (foreseeable) risk|Medium risk|High risk"]
Self-Harm: [select name="Self-harm" value="Low risk|No (foreseeable) risk|Medium risk|High risk"]
Violence: [select name="Violence" value="Low risk|No (foreseeable) risk|Medium risk|High risk"]
Vulnerability: [select name="Vulnerability" value="Low risk|No (foreseeable) risk|Medium risk|High risk"]
Absconding: [select name="Absconding" value="Low risk|No (foreseeable) risk|Medium risk|High risk"]
Other: [select name="Other" value="Low risk|No (foreseeable) risk|Medium risk|High risk"]

Risk Notes: [textarea cols=80 rows=40 default=""]

Diagnosis: [link url="http://apps.who.int/classifications/icd10/browse/2010/en#/V" memo="ICD-10 diagnoses"] [textarea cols=80 rows=2 default="Working diagnosis"]

-- Issues Identified at Initial Assessment --

[checkbox name="acaperf" value="Academic;"][conditional field="acaperf" condition="(acaperf).is('Academic;')"] in particular, the patient [checkbox value="frequently fails tests|struggles to keep up with peers|complains that the subject matter is too difficult|asserts that extracurricular activities are interfering with academic performance|lacks order and system in study|is disorganized and careless|lacks neatness|is rarely/never prepared|does not seek help when appropriate|copies from peers|engages in cheating/plagiarism|has poor attendance"] [textarea cols=80 rows=5 default=""][/conditional]

[checkbox name="sofac" value="Social;"][conditional field="sofac" condition="(sofac).is('Social;')"] in particular, the patient [checkbox value="is a loner|relates poorly to others|tends to isolate|does not fit in|feels excluded by others|is easily influenced and highly suggestible|engages in risky activities with peers|verbally criticizes peers|verbally criticizes caregivers|starts conflict without provocation|bullies and attempts to control others|does not respect rights and property of others|does not participate in group activities|interacts inappropriately with peers|is sexually inappropriate|is noncompliant with reasonable requests|frequently resists and disobeys authority|refuses to complete work assignments|does not follow rules and procedures|is socically disruptive|engages in attention seeking behaviours|is overly demanding of attention from others|has frequent tantrums in groups|frequently acts the clown|plays pranks on others|is overly dependent on others|timid/shy/dependent/anxiety-prone|is not accepted by others||does not sustain friendships|is an object of scorn/ridicule|is scapegoated/picked on|does not defend self when attacked|ostracized|social isolation|social withdrawal"] [textarea cols=80 rows=5 default=""][/conditional] 

[checkbox name="conduct" value="Conduct;"][conditional field="conduct" condition="(conduct).is('Conduct;')"] in particular, the patient [checkbox value="is verbally aggressive|frequently interrupts|starts fights|purposely agitates/disturbs/disrupts others|bullies and intimidates|frequently teases|attempts to manipulate|is overactive|is frequently inappropriate|cannot sit still and is generally restless|has numerous disciplinary offences|is malicious|is cold and calculating|lacks empathy and warmth|is cruel and punitive|has little respect for authority|is generally considered a troublemaker|is aggressive and generally violent|is destructive of own/others property|initiates physical fights|hits caregivers|is antagonistic|is frequently disobedient|is negativistic|is oppositional|is arguementative|talks back/mouthy|is defiant of authority|lies in regard to chores/homework/
house rules|complies only when threatened|is stubborn|is immature|demonstrates poor judgment|does not take responsibility for mistakes|does not own their behavior or consequences|demonstrates mutism|is prejudiced|is bigoted|insults others|vandalises|engages in hate crimes|lacks respect for authority|dares and provokes others|acts out|uses obscenities|has temper tantrums|falls to floor and tantrums|bangs head|has breath holding episodes|throws objects|screams|weeps|is generally destructive"]. [textarea cols=80 rows=5 default=""][/conditional]

[checkbox name="cogfac" value="Cognitive;"][conditional field="cogfac" condition="(cogfac).is('Cognitive;')"] in particular, the patient[checkbox value="is highly distractible|is hyperactive|is inattentive|handles novel situations poorly|lacks foresight|has low frustration tolerance|is easily confused|is unable to understand tasks|frequently daydreams|has poor concentration|is averse to change|is excessively concrete|has an inflexible and rigid thinking style|has unusual and extreme beliefs|appears intellectually delayed|is often confused and unable to accept guidance"]. [textarea cols=80 rows=5 default=""][/conditional]

[checkbox name="motdif" value="Motivational;"][conditional field="motdif" condition="(motdif).is('Motivational;')"] in particular, the patient [checkbox name="motdif" value="does not try hard with difficult tasks|generally makes little effort|is content to coast along|has the ability to do better work but lacks interest|generally shows no interest in the subject matter|does not persevere with most tasks|always needs great encouragement to complete work|gives up at first sign of difficulty|has low frustration tolerance|does not seem to pay attention|frequently daydreams|always seems preoccupied|is slow to respond|does not complete work assignments|does not make up for lost time|turns in assignments late|is careless with work|does not spend enough time on important tasks|copies from others|comes to class without necessary work materials|is frequently forgetful|misses excessive days|is known for frequent absenteeism|is always tardy|cuts classes|avoids work|is frequently truant|avoids school|refuses to attend school|refuses to attend work"] [textarea cols=80 rows=5 default=""][/conditional]

[checkbox name="becon" value="Behavioural;"][conditional field="becon" condition="(becon).is('Behavioural;')"] in particular, the patient [checkbox value="engages in alcohol/drug/substance abuse|has encopresis|has enuresis|engages in fire setting|engages in hypochondriasis|is frequently overactive and restless|engages in self injurious behaviour|hits others|bites others|engages in head banging|has a sexual preoccupation|engages in public masturbation|demonstrates inappropriate sexual behaviors|is frequently obscene|swears|makes sexualized gestures and remarks|exhibits genitals/disrobes/public nudity|wears provocative clothing|demonstrates molestation concerns|threatens others|touches others|fondles/rubs against others|engages in battery|has had forced sexual intercourse|is assaultative|has raped|threatens others|is slow moving|is slow to respond|lethargy|hypoactive|restless|fidgets|out of seat|impulsive|hyperactive/overactive|speech difficulties|thumb sucking|rocking|stereotyped movements|tics|noise or word productions|violence/aggression"] [textarea cols=80 rows=5 default=""][/conditional]

[checkbox name="afcon" value="Affect;"][conditional field="afcon" condition="(afcon).is('Affect;')"] in particular, the patient experiences [checkbox value="anxiety|fears|phobias|nervous habits|avoidance of particular certain things/actions/situations|anger|irritability|outbursts/rage/tantrums/meltdowns|tearfulness|sulking|whines|hurt feelings|low moods|feelings of  flatness|joyless|depressed|sad|unhappy|cries|feels hurt|has low energy|is easy fatigued|apathy|withdrawn|ashamed|guilty|suicidal|has limited range of emotions|expresses only high-intensity feelings|emotionally overactive|histrionic|dramatizes|plays the victim"] [textarea cols=80 rows=5 default="and other affect difficulties"][/conditional]

-- Disability impacting on recovery -- 

[checkbox name="comms" value="Understanding and Communicating"][conditional field="comms" condition="(comms).is('Understanding and Communicating')"], in particular: [checkbox value="concentrating|remembering|solving every day problems|learning a new task|understanding verbal communication|initiating and maintaining a conversation"][/conditional].

[checkbox name="gar" value="Getting around"][conditional field="gar" condition="(gar).is('Getting around')"], in particular: [checkbox value="standing for longer than 30 minutes|standing up|moving around the home|getting out of the home|walking distances greater than 1km"][/conditional].

[checkbox name="selc" value="Self-care"][conditional field="selc" condition="(selc).is('Self-care')"], in particular: [checkbox value="washing the whole body|getting dressed|eating|being alone for a few days"][/conditional].

[checkbox name="lifea" value="Life activities"][conditional field="lifea" condition="(lifea).is('Life activities')"], in particular: [checkbox value="managing a household|doing house hold tasks well|completing housework|completing housework in a timely manner|attending work|attending school|completing work tasks adequately|completing school tasks adequately|getting all work done|getting all work done in a timely manner"][/conditional].

[checkbox name="partin" value="Participation in society"][conditional field="partin" condition="(partin).is('Participation in society')"], in particular: [checkbox value="problems joining in community activities|problems because of barriers in the world|problems living with dignity due to the attitudes of others|time spend managing a health condition|Emotional impact of a health condition|impact of a health condition on finances|impact of health condition on family|problems doing things autonomously for relaxation or pleasure"][/conditional].

Communication Issues: [textarea cols=30 rows=1 default="Nil identified"]

Diagnostic Impression: [textarea cols=30 rows=1 default=""]

MEDICATIONS

Discharge Medication: [textarea cols=40 rows=30 default="nil"]

MH Medications Recently Ceased: [textarea cols=40 rows=30 default="not reported"]

Allergies and Adverse Reactions: [textarea cols=80 rows=5 default="nil known"]

RESULTS REVIEW

-- Outcome Measures --

Psychological Assessment: [textarea cols=80 rows=5 default="Nil"] 

Physical Investigations: [textarea cols=80 rows=5 default="see EMR forms"]

Other Results: [textarea cols=80 rows=5 default="see EMR forms"]

DISCHARGE INFORMATION
 
Discharge plan: [checkbox value="provided patient name the details of the expected time and date of discharge|established carer’s capability and willingness to assist|arranged for sufficient quantities of medication to last until the next consultation|checked that the patient understands the purpose, dosage, frequency and side-effects of their medication|discussed the expected recovery path and confirmed understanding|confirmed necessary follow-up appointments with the patient's healthcare provider|arranged travel assistance|provided details of the patient's medical follow-up appointments|provided contact details for community mental health services and follow up arrangements|provided contact details for private mental health services and follow up arrangements|educated the patient about signs of possible relapse and what to do|provided the patient with emergency contact numbers|provided the patient with a self-management plan (including coping strategies)|provided the patient with a crisis management plan|confirmed community support arrangements including referrals to other services / programs"].

Legal Status: [comment memo="choose one Legal Status"][checkbox value="Ambulatory - Voluntary Mental Health Client|Ambulatory - Involunatry|Ambulatory - Other|Forensic Patient|Forensic - Involuntary|No Act or legal order applies|Other|Not known|Voluntary|Involuntary"].

Trustee and Guardian details: [textarea cols=40 rows=2 default="N/A"]

Guardianship details: [textarea cols=40 rows=2 default="N/A"]

Involunatary Treatment Order details: [textarea cols=40 rows=2 default="N/A"]

Involuntary Patient Order details: [textarea cols=40 rows=2 default="N/A"]

Forensic Patient status details: [textarea cols=40 rows=2 default="N/A"]

Other Legal Status details: [textarea cols=40 rows=2 default="N/A"]

Appointments on Discharge: [checkbox value="Consultant|Registrar|Case Manager|Other Clinician"].

[textarea cols=40 rows=2 default="Nil"]

Other Services Involved: [textarea cols=80 rows=2 default="None"]

Recommended follow up: [textarea cols=80 rows=2 default="Recommended patient follow up with their GP"]

Performed by: [textarea cols=80 rows=2 default="N/A"]

Copies to: [textarea cols=80 rows=2 default="Patient's GP"]