Forensic Psychiatric Rounds – Weekly/Monthly Progress Note

Assessment: [date name="variable_1" default="07-04-2023"]
Adult [select name="variable_1" value="Black male|White male|Hispanic male"], [select name="variable_2" value="ITP|NGI"], presents for Recovery Treatment Team rounds - [select name="variable_3" value="weekly|monthly|annual|episodic"] - [text name="variable_2" default=""]. 
Patient updates: [text name="variable_3" default="none"]. Observation status: [select name="variable_4" value="RA|RS|CO on A, routine on C|TTB|Meds on Pod"].
Patient reports his mood is "[text name="variable_4" default="good"]". States sleep is "[text name="variable_5" default="good"]"", gets [text name="variable_6" default="UTA"] hours, [select name="variable_5" value="continuously|UTA|wakes up & falls back asleep easily|wakes up but has difficulty falling back asleep"]. 
Reports appetite is "[text name="variable_7" default="good"]"", [select name="variable_6" value="UTA number of meals|eats all 3/3 meals|eats all 2/3 meals|eats all 1/3 meals"], [select name="variable_7" value="UTA if eats snacks|eats snacks|eats no snacks|N/A"], restrictions: [text name="variable_8" default="none"]. 
LBM: [date name="variable_2" default="07-04-2023"], [select name="variable_8" value="AM|PM|today|UTA"], [checklist name="variable_1" value="soft|hard|loose|regular|no constipation|with constipation|dyspepsia|stool softeners|UTA"].
Reports medications are [select name="variable_11" value="working|not working|N/A none prescribed"] and [select name="variable_12" value="compliant with medications|noncompliant with medications|N/A none prescribed"]. Indicates [select name="variable_13" value="no medication side effects|medication side effects|N/A none prescribed"] and [select name="variable_14" value="no EPS/TD|EPS"] - [text name="variable_10" default="none"].
Orientation: [text name="variable_11" default="A and O x4, day"]. 
Hallucinations: [checklist name="variable_2" value="reports none|auditory|visual|tactile|gustatory|olfactory|commands|no commands"].
Delusions: [checklist name="variable_3" value="reports none|paranoid|persecutory|grandiose|somatic|ideas of reference|thought broadcasting|magical thinking"].
Reports [select name="variable_17" value="no SI|SI|SIB"] and [select name="variable_18" value="no HI|HI"] and [select name="variable_19" value="no intent/plan|intent|intent/plan"].
Participates in: [checklist name="variable_4" value="studying competency|competency class|TAP|UTA"]. 
Classes: [text name="variable_11" default="UTA"].
Demonstrates knowledge of the following competency topics: [checklist name="variable_4" value="N/A|UTA|4 pleas|definition of no contest|perjury|contempt of court|proper court room behavior|plea bargain|bailiff|probation|criteria to be discharged as NGI|Other"]. 
Needs to practice the following competency topics: [text name="variable_12" default="UTA"].
Current legal charges: [text name="variable_13" default="UTA"].
Patient questions/requests: [text name="variable_14" default="none"].
MSE: 
Appearance - [checklist name="variable_5" value="adequately groomed|hair unkempt|beard unkempt|bald|shaved head|short hair|medium hair|long hair|poor hygiene|adequate hygiene|casually dressed - appropriate|casually dressed - inappropriate|missing teeth|tattoos"]. 
Behavior -[checklist name="variable_6" value="cooperative|uncooperative|calm|rude|annoyed|restricted|malingering"]. 
Eye contact -[select name="variable_20" value="good|adequate|poor"]. 
Speech/Tone -[checklist name="variable_7" value="coherent|incoherent|fluent|hesitant|country accent|mumbling|slurred|stuttering|logorrhea|poverty|euthymic|monotone|flat|labile|annoyed"],
Speech Rate/Volume-[checklist name="variable_8" value="normal rate|rapid|pressured|labile|slow|normal volume|loud|soft|slightly"]. 
Thought process-[checklist name="variable_9" value="normal|tangential|circumstantial|flight of ideas|thought blocking|mild|moderate|severe"]. 
Thought content-[checklist name="variable_10" value="normal|perseveration|worries|obsessions/compulsions"]. 
Attention/Concentration-[checklist name="variable_11" value="adequate|distracted|easily redirectable|difficulty redirecting|not redirectable|responding to internal stimuli|"]. 
Memory-[checklist name="variable_12" value="intact|UTA|deficit|recent|remote|STM"]. 
Abstract thinking-[select name="variable_21" value="intact||concrete|poor|UTA"]. 
Psychomotor movement-[checklist name="variable_13" value="none|restless|agitation|slow|UTA"].
AIMS score: [text name="variable_15" default="not due"]. 
Affect-[checklist name="variable_14" value="congruent with mood|incongruent with mood|full|labile|blunted|flat"].
Insight-[select name="variable_22" value="fair|limited|poor"].
Judgment-[select name="variable_23" value="fair|poor"].
Other patient observations/Medical ROS/Psych ROS/PMH: [text name="variable_16" default="none"].
New Orders: [text name="variable_17" default="none"].
Diagnoses: [checklist name="variable_15" value="F20.9 Unspecified Schizophrenia Spectrum and Other Psychotic Disorder|F29 Unspecified Psychotic Disorder|F25 Schizoaffective Disorder Bipolar Type|F25.1 Schizoaffective Disorder Depressive Type|F22 Delusional Disorder|F31.9 Unspecified Bipolar Disorder|Other:"] [text name="variable_18" default="none"].
Current Medications: [checklist name="variable_16" value="Zyprexa|Haldol|Haldol deconate|Risperdal|Paliperidone|Seroquel|Abilify|Prozac|Sertraline|Mirtazapine|Buspirone|Lithium|Depakote|Divalproex ER|Trileptal|Tegretol|Ativan|Cogentin|Benadryl|Artane|Melatonin|Other:"], [text name="variable_19" default="none"].
Court ordered medications: [select name="variable_24" value="no|yes|petition pending|unknown"].