MH Patient Review

REVIEW / MANAGEMENT

-- Summary of Treatment Provided Since Last Review --

[checkbox value="AOD counselling|clinical case management|mental state monitoring|psychoeducation|family support|NGO referral|NGO support|psychiatric review|psychosocial supports|supported accomodation|sheltered employment|psychotherapy|counselling|peer support|risk management and planning|referal to suicide prevention service|referral to disability Services|inpatient admission|rehabilitation services"] [textarea default=""].

-- Date / Time of Review --

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

-- Issues / Problems Identified at Assessment --

[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="The patient"] was referred by [text default=""] for: [checkbox value="assessment|treatment|symptom monitoring|care-planning|advocacy|linking with community support services"] second to concerns over [textarea cols=30 rows=8 default=""]

-- Other Issues / Problems --

Current factors impacting on recovery include: 

[checkbox value="low motivation to change|denial of the problem|syntonic symptoms|denial of the mental health diagnosis|personality structure|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 hopeful 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 treating clincian"] [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 clinical 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 Review|Change in Patient's risk status"]

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

ASSESSMENT OF RISKS:

[checkbox name="suic" value="-- Suicide Risk Assessment --"][conditional field="suic" condition="(suic).is('-- Suicide Risk Assessment --')"] 

The Pts suicide risk status is: [checkbox value="higher than|the same as"] the general population. 

Enduring factors of concern: [checkbox value="nothing of note|Hx of denying the need for service contact|Hx of avoiding of service contact|non-responsiveness to pharmacological treatment|non-responsiveness to psychosocial interventions|personality structure|Hx of substance abuse|recent discharge from a psychiatric facility|chronic stressors|a history of self-harm|a history of previous suicide attempts|previous hospitalization for suicidality|previous hospitalization for self-harm|Hx of psychiatric illness|unstable personality structure|a background of childhood adversity|having a family history of suicide|divorced|demographic - male - single age 35-64|problem-solving difficulties|Hx of impulsive behaviour|history of significant personal loss|Hx of reckless and self-endangering behaviors|absolutistic thinking|tunnel vision|limited capacity for self soothing|perfectionistic traits|struggles with sexual orientation|guns in the home|Pt is guarded around the issue of risk|access to abundant medications|chronic medical illness|chronic pain"]. 

However, its worth noting the following strengths that offer suicide risk protection: [checkbox value="treatment responsiveness|connectedness to individuals, family, community, and social institutions|problem-solving skills|coping skills|ability to adapt to change|a sense of purpose or meaning in life|personal beliefs that discourage self-injury|good social skills|ability to manage feelings of anger|good health|access to mental and physical health care|healthy fear of risky behaviours and pain|hope for the future and optimism|sobriety|medical compliance|a sense of the importance of health and wellness|impulse control|a strong sense of self-worth or self-esteem|a sense of personal control or determination|access to a variety of clinical interventions|help seeking behaviours|resiliency|expressed reasons for living|being married|being a parent|strong relationships|supportive friends|supportive family members|supportive spouse|opportunities to participate in and contribute to school or community projects and activities|living in a reasonably safe and stable environment|having restricted access to lethal means|sense of responsibility and duty to others|being a pet owner"] [textarea default=""].

The Pts suicide risk state is currently [checkbox value="elevated|at baseline"]. 

Factors affecting the Pts risk state include: [checkbox value="nothing of note|untreated mental illness|suicidal thinking|homelessness|personality disorder Sx|current stressors|lack of distress tolerance skills|lack of therapeutic alliance|access to lethal means|feels abandonned|feels socially undesirable|withdrawal from support groups|relationship breakdown|isolating and withdrawing from others|treatment non-compliance|abuse of substances|psycho-social stressors|feelings of hopelessness|feelings of anger|lack of vocational skills|unmet needs|external locus of control|rejection from peer group|recent loss of status|recent loss of ambitions|current suicidal plan|plan lethality|preparation behaviours|vocalising threat to suicide|rehearsal behaviours|recent suicide attempt|regrets not dying|acute mood disorder|increased substance abuse|mood lability|suicide command hallucinations|insomnia|persistent nightmares|unremitting pain|persistent distress|persistent agitation|tearfulness|guarded and difficult to assess|withdrawal from services|comorbid MH concerns|feelings of hopelessness|severe anhedonia|severe depression|loss of self-esteem|feelings of shame|feeling intolerably alone|feeling trapped|no reasons for living|loss of purpose and meaning|increased impulsivity|increased recklessness|increased anger|seeking revenge|recent violent behaviours|final act behaviours|stalking|intense jealousy over ex|recent loss of relationship|loss of social support|recent discharge from MH-IPU|loss of job|increasing financial pressure|loss of status|recent suicide of a loved one|declining health|pending legal issues|pending criminal charges|feeling victimised"] [textarea default=""].

Available support resources include: [textarea default="Mental Health Line 1800011511, The Acute Care Service, Case Manager, Beyond Blue 1300224636, Lifeline 131114, Mensline 1300789978, QLife 1800184527, Suicide Callback Service 1300659467, Safehaven, Veterans Support 1800011046, Rekindling the Spirit, presenting to the ED after hours, Family, Partner, Friends"]

Foreseeable risk changes of concern include: [textarea default=""][/conditional]

Self-harm: [textarea cols=50 rows=2 default="No foreseeable risks apparent from our last contact, and no historical risks reported"]

Violence: [textarea cols=50 rows=2 default="No foreseeable risks apparent from our last contact, and no historical risks reported"]

Vulnerability:[textarea cols=50 rows=2 default="No foreseeable risks apparent from our last contact, and no historical risks reported"]

Harm to U18s: [textarea cols=50 rows=2 default="No foreseeable risks apparent from our last contact, and no historical risks reported"] 

Absconding: [textarea cols=50 rows=2 default="No foreseeable risks apparent from our last contact, and no historical risks reported"]

Other risks: [textarea cols=50 rows=2 default="No foreseeable risks apparent from our last contact, and no historical risks reported"]

IMPRESSION AND PLAN

-- Formulation --

[text default="Name"] is a [text default="X year old"] [select value="female|male"] [select value="voluntary|involuntary"] Patient, presenting with: [checkbox value="substance misuse concerns|acute mental health distress|multiple complex psychosocial issues|a developmental disorder|schizophrenia spectrum disorder|situational crisis|thoughts of suicide|thoughts of harm to others|thoughts of self-harm|NSSI|superficial self-harm|serious self-harm behaviours|bipolar disorder|depressive disorder|anxiety disorder|OCD|a trauma and stress related disorder|a dissociative disorder|a somatic symptom disorder|a feeding and eating related disorder|an elimination related disorder|a sleep-wake disorder|sexual dysfunction|gender dysphoria|impulse control related disorder|substance related disorder|a neurocognitive disorder|a personality disorder"] [textarea default=""], which, at the time of their referral, was characterised by these symptoms: [checkbox value="fear and worry|panic|behavioural avoidance|clinging and neediness|pacing|anxiety|irritability|low mood|sadness|inner emptiness|anhedonia|poor concentration|disturbed sleep cycle|guilt|low self-worth|hopelessness|thoughts of suicide|parasuicidal behaviours|suicidal behaviours|deliberate self-injury|disturbed sleep|dissociation|provocative behaviours|compulsions|domineering others|eccentricities|emotional detachment|negativism|denial|projection|splitting|passivity|loss of appetite|increase in appetite|lethargy|euphoria|excessive energy|talkativeness|racing thoughts|grandiosity|impulsivity|insomnia|decreased need for sleep|flashbacks|nightmares|intrusive thoughts|heightened threat sensitivity|perceptual disturbance|disorganised thinking|disorganised behaviours|agitation|cognitive difficulties|speech difficulties|hallucinations|delusions|vulnerabilty to exploitation|social withdrawal|amotivation|impaired reality-testing|unhealthy weight loss|unhealthy weight gain|medical problems associated with low BMI|body dysmorphia|alexithymia|medical problems associated with high BMI|family discord|purging|unhealthy weight loss techniques|preoccupation with food|over-valued body ideals|inattention|distractibility|hyperactivity|intellectual difficulties|social difficulties|obsessions|unhealthy preoccupations|cognitive inflexibility|poor social reciprocity|language difficulties|insightlessness|treatment refusal|poor medication adherence|legal difficulties|debts|reputational damage|housing difficulties|unemployment|poverty|unhealthy lifestyle choices|financial stress|oppositional behaviours|hostility towards treatment and support services in general|substance misuse|medication misuse"] [textarea default=""].
 
The current treatment includes: [checkbox value="counselling|clinical case management|mental state monitoring|psychoeducation|family support|NGO Support|psychiatric medication|psychosocial supports|supported accomodation|sheltered employment|a legal order|psychotherapy|peer support|risk management and planning|occassional ACS contact and monitoring|NDIS support|an inpatient admission|rehabilitation services"] [textarea default=""].  

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=""]  [textarea cols=80 rows=1 default=""].

Factors promoting recovery include: [checkbox value="good adjustment and coping skills|good cognitive reappraisal skills|acceptance of the illness as real|good understanding of the impact of illness|good response to medications|minimal side effects of medications|strong self-concept|ability to self-reflect|ability to take ownership of recovery|a sense of agency|internal locus of control|exploits strengths|is hopeful for future|desiring change|takes responsibility for health habits|uses occupation and distraction in managing symptoms|good social supports|close relationships|has a sense of belonging|values friends and peers|has family support|has cultural attitudes promoting recovery|feels cared for|is realistic|maintains a sense of meaning in life|symptoms are manageable|is psychologically minded|good rapport with case manager|well engaged with support services|attends social events"]

Recovery progress to date has been [select value="good|fair|static|minimal"]

-- 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 default=""]
REVIEW / MANAGEMENT

-- Summary of Treatment Provided Since Last Review --

.

-- Date / Time of Review --

Date:
Time:

-- Issues / Problems Identified at Assessment --

.

-- Reason for Referral --

was referred by for: second to concerns over


-- Other Issues / Problems --

Current factors impacting on recovery include:



-- Summary of Progress --

At our last contact I would rate the severity of illness as .

Compared to their condition on admission, I rate progress as: .

-- Consumer View of Progress --

When asked to rate clinical progress, reported .

-- Reason for Review --



MEDICATIONS:


ASSESSMENT OF RISKS:



Self-harm:


Violence:


Vulnerability:


Harm to U18s:


Absconding:


Other risks:


IMPRESSION AND PLAN

-- Formulation --

is a Patient, presenting with:
, which, at the time of their referral, was characterised by these symptoms:
.

The current treatment includes:
.

Factors impacting on recovery include:

.

Factors promoting recovery include:

Recovery progress to date has been

-- Diagnosis --



-- Action Plan Following The Review --



-- Clinicians Involved In The Review --

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.41, 55 form elements, 168 boilerplate words, 8 text boxes, 24 text areas, 15 checkboxes, 7 drop downs, 1 conditionals, 528 total clicks
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