DEPOT NOTE

DEPOT NOTE

Situation

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[text default="PATIENT"] attended Community Mental Health for [text default="his her"] depot today. DEPOT was administered by [text default="The Author"].

Given [text default="dose"] of [text default="med"] [text default="IMI"] as charted  on medication chart.

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Objective   

Pt is a [checkbox value="young adult|mid-aged adult|older adult|young teen|older teen|child"] - [checkbox value="male|female"].
[checkbox value="Reasonably|Not well|Meticiulously"] kempt.
[checkbox value="average weight|overweight|underweight"] relative to size.
Posture [checkbox value="relaxed|rigid|looked ill-at-ease|stooped|confident|aggressive|tense|slumped"]
Movement [checkbox value="unremarkable|odd / peculiar|slowed|repetitive|restless|agitated|tremorous"][checkbox value="+|++|+++"]
Attention: [checkbox value="no concerns - attended well|seemed unaware|inattentive|distractible|hyper-vigilant|scattered concentration|preoccupied|confused|focused on irrelevancies"][checkbox value="+|++|+++"]
Engagement: [checkbox value="no concerns - warm, chatty, and engaged well|avoided eye contact|fixed staring|glaring at author|tense facial expression|dependent and needy|dramatic and exaggerating concerns|passive and difficult to engage|uninterested|silly and joking around|resistant|critical and verbally combative|hostile and threatening|sarcastic and taunting|irritable|fatuous|flirtatious|demanding|threatening|guarded|paranoid|defensive and resistant|cold, aloof and inaccessible|manipulative|argumentative"][checkbox value="+|++|+++"]
Mood reported: [text default="Fine"]
Affect observed: [checkbox value="mainly euthymic|tearful|labile|restricted|blunted|flat|dysphoric|anxious|angry|apathetic|ashamed|prideful|sad|irritable|hostile|pessimistic|depressed|manic|euphoric"][checkbox value="+|++|+++"]
Speech: [checkbox value="spontaneous|normal RTV|abnormal RTV|clear and articulate|selectively mute|mute|loud|laconic|verbose|quiet|pressured|rambling|babbling|incongruent with mood and current circumstances"]
Thinking: [checkbox value="logical|linear|rigid and concrete|personalizing|persecutory|indecisive|unrealistic|difficulties of reference|magical ideas of influence|distorted|pseudologica fantastica|memory difficulties|provided unnecessary detail (circumstantial)|wandered between many topics (tangential)|jumped from one idea to another (loose associations)|racing thoughts (flight of ideas)|abruptly changed topic or stopped mid-sentence (thought blocking)|tended to loop or repeat themes (obsessive)|stuck on over-valued ideas (preoccupations)"][checkbox value="+|++|+++"]
Orientation: [checkbox value="no concerns|AH reported|VH reported|poor judgement|poor reality testing|poor insight|complete denial"][checkbox value="+|++|+++"]
Stressors disclosed without prompting: [checkbox value="nil|self-esteem|parenting|spouse|money|school|physical health|energy|sleep|body weight\shape|eating|food|housing|employment|mood|family|work|grief and loss|illness|transitions|legal|peers|relationship"][checkbox value="+|++|+++"]
Suicide risk: [select value="denied active suicidal ideation when asked|vague suicidal ideation|intense suicidal ideation|has a suicide plan without strong intent|has strong intent to suicide without a plan|has strong intent and a plan to complete suicide"].

Plan : Next depot [date default="DAY, XX/XX/2018"]
[textarea default="Next contact DATE"]