REVIEW / MANAGEMENT

-- Summary of Treatment Provided Since Last Review --

[textarea cols=20 rows=1 default="This patient"] is a [text default="age"] year old [select value="Female|Male"] with a primary diagnosis of: [textarea cols=50 rows=1 default="Diagnosis"] and has been case managed since [text default="year"].

[select value="She|He"] is currently being treated with: [textarea cols=50 rows=1 default="Treatment"]

-- Date / Time of Review --

Date: [text default="DATE"]
Time: [text default="Time"]

-- Issues / Problems Identified at Assessment --

My assessment also revealed difficulties with: [checkbox value="symptom severity|intrusive thoughts|physical illness|bereavement|family health difficulties|adjusting to stage of life|substance withdrawal|upheaval of lifestyle|substance misuse|divorce|separation from partner|relationship problems|imprisonment|poverty|personal injury|marital 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|education pressure|change in residence|change in school|church|religion|change in social activities|addictions|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|marginalization|social withdrawal and isolation|unable to make friends"][textarea cols=80 rows=10 default=""].

-- 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.

-- Other Issues / Problems --

Current 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=""]

-- Summary of Progress --

At our last contact I would rate the severity of [text default="the patient's"] illness as [select value="stable and without symptoms|fully recovered|mildly ill|moderately ill|severely ill|among the most extremely ill patients"].

Compared to their condition on admission, I rate [text default="the patient's"] progress as: [select value="very much improved|much improved|minimally improved|no change|minimally worse|much worse|very much worse|unable to be assessed"].

-- Consumer View of Progress --

When asked to rate their progress, [text default="the patient"] reported [select value="very much improved|much improved|minimally improved|no change|minimally worse|much worse|very much worse|they don't know"].

-- Reason for Review --

[select value="13-Week Review|Risk Re-Assessment"]

MEDICATIONS:

[textarea cols=50 rows=1 default="Medication"]

ASSESSMENT OF RISKS:

Suicide: [textarea cols=30 rows=1 default="No identified risks"]

Self-harm: [textarea cols=30 rows=1 default="No identified risks"]

Violence: [textarea cols=30 rows=1 default="No identified risks"]

Vulnerability:[textarea cols=30 rows=1 default="No identified risks"]

Harm to U18s: [textarea cols=30 rows=1 default="No identified risks"]

Absconding: [textarea cols=30 rows=1 default="No identified risks"]

Other risks: [textarea cols=30 rows=1 default="No identified risks"]

IMPRESSION AND PLAN

-- 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=50 rows=1 default="Diagnosis"]

-- Action Plan Following The Review --

[textarea cols=70 rows=20 default="Continue with current treatment"]

-- Clinicians Involved In The Review --

[textarea cols=80 rows=20 default=" and the author"]