Crisis Unit

COMMON GROUND  

Date and Time of Service: [date default=timestamp]
Cheif Complaint:
[textarea name="variable_97" default="" rows=3] 

Client is a [text name="variable_3" default=""] year old [checkbox name="variable_4" value="Caucasian|African American|Hispanic|Asian|Native American|Biracial"][text name="variable_5" default=" "][comment memo="other"] [checkbox name="variable_6" value="male|female"][textarea memo="other" default="" rows="1"] 

Client reports a hx of:
[textarea memo="Past Dx, who diagnosed" name="variable_24" default=" " rows="3"]
[textarea memo="Interval Hx, Onset, duration" default=" " rows="8"]
[textarea memo="Current Psychiatric Medication" name="variable_14" default="Current medications " rows="3"] 
[textarea memo="Past Psychiatric Medications" name="variable_99" default="Previous medications treatment included " rows="3"][textarea memo="Tx response" default=" " rows="6"]
Medication Compliance: [checkbox name="variable_98" value="Compliant|Non-compliant"]

Client presents with the following symptoms:
[checkbox value="agitation"][checkbox name="variable_8" value=" depressed mood|loss of interest/pleasure|weight loss|weight gain|insomnia| hypersomnia|psychomotor retardation|psychomotor agitation|fatigue|feelings of worthlessness/excessive or inappropriate guilt|decreased concentration/indecisiveness|thoughts of death/suicide|excessive anxiety and worry|finds it difficult to control the worry|anxiety and worry are associated with restlessness or feeling keyed up or on edge|being easily fatigued|dificulty concentrating or mind going blank|irritability|muscle tension|sleep disturbance"] [textarea name="variable_9" default="" rows="1"][comment memo="other"] [textarea memo="Previous symptoms" default="" rows="2"] [textarea memo="Onset" default="" rows="2"] [textarea memo="Location" default="" rows="2"] [textarea memo="Duration of symp" default="" rows="2"] [textarea memo="Characteristics" default="" rows="2"] [textarea memo="Aggravating factors" default="" rows="2"] [textarea memo="Relieving factors" default="" rows="2"] [textarea memo="Timing" default="" rows="2"] [textarea memo="severity" default="Today, client rates depression /10, anxiety /10, stress /10, and describes appetite as __poor __fair __good, sleep as __poor __fair __good." rows="4"]

The client reports the symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning:
[checkbox value="" rows="3"] [checkbox value="Client denies any "][checkbox name="variable_15" value="auditory hallucination|visual hallucinations|racing thoughts|excessive worry|suicidal ideation|homicidal ideation|thoughts of self-harm or self-injury|thoughts of harm to others"] [textarea name="variable_28" default=" " rows="1"]

PAST PSYCHIATRIC HISTORY
[checkbox value="Psychiatric history obtained by record"] [textarea memo="medication trials / as noted in HPI" default="" rows="4"] [checkbox value="Client denies any previous history of"][checkbox value=" psychiatric diagnosis|psychiatric care|hospitalization|outpatient treatment|past suicide attempts|self-injury|violent behavior to others"] [checkbox value="Denies taking any previous psychiatric medications." comment memo="denies med trial"]

SUBSTANCE USE/ ADDICTIVE BEHAVIORS
[checkbox value="Declines to answer"][textarea memo="qty,frequency,last drink, past tx" default="" rows="2"] [checkbox value="Denies using nicotine or tobacco products|Denies any alcohol use|Denies using illicit drugs.|Denies using|stimulants|opiates|marijuana|hallucinogens|synthetics|bath salts|club drugs."] [checkbox value="Denies any addictive behaviors such as eating, spending, gaming, gambling, or sexual addictions."]

FAMILY PSYCHIATRIC HISTORY:
[checkbox value="unknown"] [textarea memo="biological, adopted?, unknown?, med trial" default="" rows="2"] [checkbox value="Client denies any family history of"] [checkbox value=" mental health disorders|suicide attempts|completed suicide by any other family members."]

MEDICAL HISTORY: [textarea memo="" default="" rows="2"] [checkbox value="Client denies any history of|client endorses history of"][checkbox value="cardiac|respiratory|endocrine|neurological|head injury|HIV|hepatitis|Denies any surgical history."]

CURRENT MEDICATIONS:  [textarea memo="Current med list" default=" " rows="2"] [checkbox value=" Denies taking any other medications|Denies taking herbals or supplements|Denies OTC meds"]

ALLERGIES: [textarea memo="meds/food" default="" rows="2"] [checkbox value="Denies any medication allergies.|Denies any food allergies."]

PSYCHOSOCIAL:
[checkbox name="variable_22" value="single|married|separated|divorced|in a relationship|widowed|a widower|no children.|1 child.|has children and actively parenting.|has children, not actively parenting.|has grown children."] [checkbox name="variable_17" value="Lives alone.|Lives with partner.|Lives w/ roommates.|Lives with parents.|Currently homeless."] [textarea memo="Lives with other" name="variable_26" default="" rows="1"] 
EDUCATION:
[checkbox name="variable_18" value="No formal education|Elementary school completed|Some highschool-did not graduate|High school graduate|GED|Vocational program completed|College graduate"][textarea memo=" " default="" rows="1"]
EMPLOYMENT:
[checkbox name="variable_19" value="Unemployed|Employed|on Disability|on Social Security|Reports being financially independent."][textarea memo="job title" name="variable_27" default=" " rows="1"][textarea memo="comments" default="" rows="1"] 
RELIGIOUS/SPIRITUAL:
[checkbox value="Denies current involvement in church or other religious or spiritual organizations.|Currently involved in church or other spiritual organization."] 
FAMILY:
[textarea memo="Client was raised by , birth order, developmental, Client reports having a good relationship with , Denies any developmental delay." default="" rows="4"] 
LEGAL / MILITARY
[checkbox name="variable_20" value="Denies any current legal issues or pending charges|Client is on probation|Client is on parole|Client has pending charges|"][textarea memo="which county? ROI?" default="" rows="1"] [checkbox name="variable_21" value="Denies any previous military experience|Client has military experience|Client is a veteran"]

(OBJECTIVE)

MENTAL STATUS EXAM: 
Appearance: [select value="stated age|older than stated age|younger than stated age"], [select value="neat|disheveled"][textarea memo="other" default="" rows="1"].
Gait and Station / Muscle Strength and Tone: [select name="c" value="Steady gait while walking, normal strength bilaterally|"][conditional field="c" condition="(c).is('')"]
[checkbox value="steady gait while walking|unsteady gait while walking|clumsy|unable to ambulate|in bed|in wheelchair|assisted by cane|assisted by walker|rigid|spastic|normal strength bilaterally|weakness noted in "][/conditional][textarea memo="other" default="" rows="1"].
Mood and Affect:
Mood- [checkbox value="euthymic|depressed|anxious|angry|irritable|happy|fluctuating"][textarea memo="other" default="" rows="1"].
Affect- [checkbox value="sad|tearful|anxious|flattened|restricted|irritable|happy|full range"][textarea memo="other" default="" rows="1"].
Speech: [select value="Normal rate and rhythm, not pressured|pressured|paucity"][textarea memo="other" default="" rows="1"].
Thought process: [select value="logical, linear, age appropriate|circumstantial|"][textarea memo="other" default="" rows="1"].
Associations: [select value="intact|loose|tangential|"][textarea memo="other" default="" rows="1"].
Thought Content: [select value="no evidence of delusions, |"][select value="no evidence of response to internal stimuli, |"][select value="no suicidal ideation or intentions, |"][select value="no homicidal ideation or intentions|"][textarea memo="other" default="" rows="1"].
Orientation: [select value="Oriented to person, place, and time|unable to assess due to cognitive impairment|"][textarea memo="other" default="" rows="1"].
Attention and Concentration: [select value="Adequate attention and concentration based on answers to interview questions|unable to assess due to cognitive impairment|impaired attention and concentration as evidenced by |"][textarea memo="other" default="" rows="1"]
Memory: [select value="Recent and remote memories both intact based on patient's answers to interview questions|unable to assess due to cognitive impairment|"][textarea memo="other" default="" rows="1"]
Language: [select value="No evidence of aphasia |unable to assess due to cognitive impairment|"][checkbox value="able to name objects|able to repeat phrases"] [textarea memo="other" default="" rows="1"]
Judgment and Insight:
Judgment- [select value="fair|good|poor|impulsive"][textarea memo="other" default="" rows="1"].
Insight- [select value="fair|good|poor"][textarea memo="other" default="" rows="1"]
Fund of Knowledge: Based on the answers to interview questions, patient's intelligence is judged to be [select value="average|above average|below average|unable to assess due to cognitive impairment"][textarea memo="other" default="" rows="1"]


[textarea memo="DATA REVIEWED: " default=" " rows="1"][checkbox value="I have reviewed the following "][checkbox value="previous records|intake records|transfer records|labs|imaging|referral records"] [textarea default="" rows="1"][comment memo="I obtained collateral information from|family member|staff. I consulted with medical director"]
[checkbox value=" I reviewed PDMP|No report found in client's name.|no concerns.|and found abnormal results."][textarea default="" rows="2"]

Medications Dispensed at This Visit:
[textarea name="variable_93" default="" rows="3"]

Patients Preferences: [textarea name="variable_91" default="CRU" rows="2"]

Recovery Based Language: [checkbox name="variable_95" value="precontemplation|contemplation|maintenance|action|preperation"]

Guardianship:
[checkbox name="variable_89" value="patient does not have a guardian|patient has a guardian"] 
Guardian Contact:[textarea name="variable_87" default="" rows"2"]

ASSESSMENT:
 [checkbox value="Client meets DSM-5 Criteria for |Diagnostic Impression: "][textarea memo="other" default="" rows="5"]

PLAN: [textarea memo="meds, psychotherapy, black-box warning" default="Client was educated on the recommendation for treatment, including the following: " rows="8"]
[checkbox value="Client was counseled on benefits, risks, side effects, reviewed alternative treatments, including no treatment, and answered all client questions. "] [checkbox value="Client counseled to notify the clinic/provider of any side effects, adverse reaction, changes in thought, or worsening mood, SI/HI/DTS/DTO, go to ER, or call 911, or crisis hotline."] [checkbox value="Client verbalizes understanding and agrees with the treatment plan."] [checkbox value="The client and/or parent or legal guardian received medication information in the form of a medication information handout."] [checkbox value="Medications have been discussed with parents or legal guardians. "]