-- Summary of Treatment Provided Since Last Review --
[textarea cols=20 rows=1 default="The 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"]
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, symptom monitoring, care-planning, advocacy and linking with rehabilitation and community 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="Change in clinical status|Routine 13-Week Review|Change in Patient's risk status"]
Other risks: [textarea cols=30 rows=1 default="No foreseeable risks"]
IMPRESSION AND PLAN
-- Formulation --
[text default="the patient"] presents with a diagnosis of [textarea cols=30 rows=1 default=""] that includes symptoms of [textarea cols=80 rows=1 default=""]. The current treatment is [textarea cols=30 rows=1 default=""]. Recovery progress to date has been [select value="good|fair|static|minimal"] which is likely due to [textarea cols=80 rows=1 default=""].
-- Diagnosis --
[textarea cols=50 rows=1 default="Diagnosis"]
-- Action Plan Following The Review --
[textarea cols=70 rows=20 default="Continue with current treatment"]