Initial Psych

DATE OF ADMISSION: [comment memo="ADMI DATE" memo_size="large"][text name="variable_admidate" default=""]
REASON FOR ADMISSION: [comment memo="ADMI REASON" memo_size="large"][text name="variable_admireason" default=""]
 
Identifying information:    [comment memo="AGE" memo_size="large"][text name="variable_age" default=""] y/o [comment memo="RACE" memo_size="large"][select name="variable_race" value="White|African    American|Asian"] [comment memo="GENDER" memo_size="large"][select name="variable_gender" value="male|female"] .

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HPI
 
Case of a [comment memo="AGE" memo_size="large"][text name="variable_age" default=""] y/o [comment memo="GENDER" memo_size="large"][select name="variable_gender" value="male|female"] with PMHx of [var name="variable_medhx"], [comment memo="PAST PSYCH HISTORY" memo_size="large"][text name="variable_pastdx" default="" size=100], who arrived to ED due to [comment memo="SYMPTOMS" memo_size="large"][checkbox name="variable_symptoms" value="depressed mood; including little pleasure in doing things, hopelessness, helplessness, lack of energy, poor concentration, changes in appetite, psychomotor retardation, poor sleep|and SI|anxiety;  nervousness, restlessness, muscle tension, difficulty concentrating, irritability, sleep disturbance|mania; elevated mood, distractibility, impulsivity, grandiosity, flight of ideas, anxiety, pressured speech|panic, palpitations, sweating, nausea, shortness of breath, dizziness, chills, fear of dying or going crazy|recurrent intrusive memories, nightmares, flashbacks, low interest in activities and persistent negative emotional state, detachment from others, hypervigilance, exaggerated startle response, emotional outbursts|delusional thoughts, hallucinations"] for [comment memo="Onset" memo_size="large"][text name="variable_onset" default=""]. Patient    is    currently  [comment memo="CURRENT MEDICATIONS" memo_size="large"][text name="variable_meds" default="prescribed" size=100] Patient [comment memo="SI"][select name="variable_SI" value="denied SI, HI, |reported SI _____, denied HI,|reported HI_____, denied SI,"][select name="variable_hallu" value="hallucinations, delusions or paranoia|reported hallucinations _____|reported delusions ____|reported hallucinations and delusions _____"].
 
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ROS:[comment memo="ROS" memo_size="large"]
 
- Depression: [select name="variable_rosdepre" value="N/A|depressed mood, feelings of hopelessness and helplessness, anhedonia, changes in appetite, difficulty sleeping"]
- Anxiety: [select name="variable_rosanx" value="N/A|anxious mood, restlessness, constant worry, muscle tension, rapid heart beat"]
- Mania: [select name="variable_rosmanic" value="N/A|high levels of energy, elevated mood, pressured and overproductive speech, increased goal directed activities, flight of ideas, difficulty sleeping, psychomotor agitation"]
- PTSD: [select name="variable_rosptsd" value="N/A|intrusive memories, nightmares and sleep disturbance, flashbacks, avoidance, disociative amnesia, persistent negative emotional state, low interest in participating in activities, inability to experience positive emotions, hypervigilance, exaggerated startle, aggressive behavior "]
- Psychosis: [select name="variable_rospsycho" value="N/A|persecutory delusions, grandiose delusions, somatic delusions, referential delusions, auditory hallucinations, visual hallucinations, disorganized speech, word salad, neologisms, catatonia, agitation, echolalia, echopraxia, stereotyped movements, flat affect, affective flattening, anhedonia, alogia  "]
- Impulsiveness: [select name="variable_rosimpulsive" value="N/A|Angry outbursts, daredevil behavior, destruction of property, hyperactivity/impulsivity, substance-use-related behaviors"]
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PAST PSYCHIATRIC HISTORY
 
- Medications:[comment memo="PAST MEDICATIONS" memo_size="large"]
[textarea name="variable_pastmedtrials" default=""]
 
- Hospitalizations: [comment memo="HOSPITALIZATIONS" memo_size="large"][checkbox name="priorhospi" value="no prior hospitalizations|prior hospitalizations"]
 
- Suicide attempts: [comment memo="SUICIDE ATTEMPTS" memo_size="large"][checkbox name="suicideattempts" value="no previous suicide attempts|previous suicide attempts"]
 
- Rehab/Therapy: [comment memo="REHAB/THERAPY" memo_size="large"][checkbox name="rehab" value="No|Yes"][conditional field="rehab" condition="(rehab).is('Yes')"], times: [text name="attempts"][/conditional]
 
- Abuse/trauma: [comment memo="TRAUMA" memo_size="large"][checkbox name="abuse" value="No|Yes"][conditional field="abuse" condition="(abuse).is('Yes')"], type: [text name="attempts"][/conditional]
 
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Medical History[comment memo="MedHx"]
 
- [comment memo="MEDICAL CONDITIONS" memo_size="large"][textarea name="variable_medhx" default=""]
 
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FAMILY HISOTRY
 
- Mother: [comment memo="MOTHER PSYCH" memo_size="large"][checkbox name="momhx" value="No|Yes|Unknown"][conditional field="momhx" condition="(momhx).is('Yes')"], psychiatric condition/s: [text name="psycconmom"][/conditional]
- Father: [comment memo="FATHER PSYCH" memo_size="large"][checkbox name="dadhx" value="No|Yes|Unknown"][conditional field="dadhx" condition="(dadhx).is('Yes')"], psychiatric condition/s: [text name="psyccondad"][/conditional]
- Suicide: [comment memo="FAM SUICIDE" memo_size="large"][checkbox name="suifam" value="No|Yes|Unknown"][conditional field="suifam" condition="(suifam).is('Yes')"], relative: [text name="psycconmom"][/conditional]
 
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SOCIAL HISTORY
 
- Living situation: [comment memo="LIVING" memo_size="large"][checkbox name="living" value="currently living in private home|homeless|currently living in government issued home|currently living with roommate"]
- Marital status: [comment memo="MARITAL" memo_size="large"][select name="variable_marital" value="Single|Married|Separated|Divorced|Widow"]
- Children: [comment memo="CHILDREN" memo_size="large"][checkbox name="children" value="No|Yes"][conditional field="children" condition="(children).is('Yes')"], total of: [text name="totalchildren"][/conditional]
- Social support: [comment memo="SUPPORT" memo_size="large"][checkbox name="support" value="has social support|lacks social support"]
- Occupation: [comment memo="OCCUPATION" memo_size="large"][checkbox name="job" value="Unemployed|Employed"][conditional field="job" condition="(job).is('Employed')"], occupation: [text name="occupation"][/conditional]
- Legal: [comment memo="LEGAL PROBLEMS" memo_size="large"][checkbox name="legalprob" value="No|Yes"][conditional field="legalprob" condition="(legalprob).is('Yes')"], problem: [text name="legalprobs"][/conditional]
 
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CURRENT MEDICATIONS:
|ACTIVE MEDICATIONS|
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ALLERGIES:
 |ALLERGIES LOCAL AND REMOTE|
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VITAL SIGNS:
  |VITAL SIGNS TODAY|
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LABS:
 
|VALPROIC ACID 1Y|
 
|LITHIUM 1Y|
 
 
|LAB PAST 30 DAYS|
 
IMAGING:
 
- CT Brain:[comment memo="CT SCAN" memo_size="large"][textarea name="variable_ctbrain" default=""]
 
|EKG (MOST RECENT)|
 
- ECG: [comment memo="ECG" memo_size="large"][select name="variable_ecgfind" value="normal sinus rythym|abnormal rythym ______"]
 
- QTc: [comment memo="QTc" memo_size="large"][text name="variable_qtc" default=""]
 
Lab results were reviewed and treatment plan updated as needed.
 
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Mental Status Exam (MSE)[comment memo="MENTAL STATUS" memo_size="large"]
 
-    Orientation: oriented to [select name="variable_orientation" value="person, time, place|person only"].
-    Appearance: [select name="variable_appearance" value="dressed appropriately for weather, well nourished|disheveled "].
-    Behavior: [select name="variable_behavior" value="calm,cooperative|agitated, in psychological distress|withdrawn, with poor eye contact"].
-    Mood: [select name="variable_mood" value="euthymic|depressed"].
-    Affect intensity: [select name="variable_affect" value="congruent with mood|blunted|flat"].
-    Thought process: [select name="variable_process" value="logical, coherent and organized|tangential|circumstantial"]
-    Thought content: [select name="variable_content" value="no signs of perceptual disturbances|paranoia|delusional thoughts|broadcasting|thought insertion|fixation and rumination"]
-    Attention: [select name="variable_attention" value="no difficulty with attention or concentration|had some attentional and concentration problems during the exam"].
-    Insight: [select name="variable_insight" value="fair|poor"].
-    Judgment: [select name="variable_judgement" value="fair|poor"].
-    Cognition/Memory: [select name="variable_cognition" value="grossly intact|below average"].
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SUICIDE RISK SCREEN:
 
|VA-SUICIDE SCREEN|
 
- Assessment of firearms: [comment memo="FIREARMS" memo_size="large"][checkbox name="firearms" value=" Not accessible| Accessible, counseled about risk"][conditional field="firearms" condition="(firearms).is(' Accessible, counseled about risk')"]. Storage: [select name="variable_storage" value="Unloaded|Loaded|Gun lock used"][/conditional]
 
- ACUTE RISK: [comment memo="ACUTE RISK" memo_size="large"][select name="variable_risk1" value="Low|Intermediate|High"]
Rationale for risk level: Veteran [var name="variable_SI"]shows desire to live, a reasonably safe and stable environment, help-seeking behavior, good self-esteem, support through ongoing medical and mental health care, effective clinical care and shows good treatment engagement. 
 
 
- CHRONIC RISK: [comment memo="CHRONIC RISK" memo_size="large"][select name="variable_risk2" value="Intermediate|Low|High"]
Rationale for risk level: Veteran has chronic [var name="variable_dx1"],[var name="variable_dx2"], [var name="priorhospi"], [var name="suicideattempts"], [var name="living"], [var name="support"], but shows to have good history of help-seeking behavior, has good access to MH care and engagement in treatment when needed.
 
 
HOMICIDE RISK:  [comment memo="HOMICIDE" memo_size="large"]
Homicidal/violence history/risk: Denies HI, no behavioral red flags per CPRS, no aggressive behavior during this admission.
 
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DIAGNOSTIC IMPRESSIONS:[comment memo="DIAGNOSIS" memo_size="large"]
 
- [comment memo="DIAGNOSIS 1" memo_size="large"][select name="variable_dx1" value="|Major Depressive Disorder, Single Episode|Major Depressive Disorder, Recurrent Episode|Persistent Depressive Disorder (Dysthymia)|Disruptive Mood Dysregulation Disorder|Premenstrual Dysphoric Disorder|Substance/Medication-Induced Depressive Disorder|Depressive Disorder Due to Another Medical Condition|Other Specified Depressive Disorder|Unspecified Depressive Disorder||Bipolar I Disorder|Bipolar II Disorder|Cyclothymic Disorder|Substance/Medication-Induced Bipolar and Related Disorder|Bipolar and Related Disorder Due to Another Medical Condition|Other Specified Bipolar and Related Disorder|Unspecified Bipolar and Related Disorder||Separation Anxiety Disorder|Selective Mutism|Specific Phobia|Social Anxiety Disorder (Social Phobia)|Panic Disorder|Panic Attack (Specifier)|Agoraphobia|Generalized Anxiety Disorder|Substance/Medication-Induced Anxiety Disorder|Anxiety Disorder Due to Another Medical Condition|Other Specified Anxiety Disorder|Unspecified Anxiety Disorder||Reactive Attachment Disorder|Disinhibited Social Engagement Disorder|Posttraumatic Stress Disorder (PTSD)|Acute Stress Disorder|Adjustment Disorders|Other Specified Trauma- and Stressor-Related Disorder|Unspecified Trauma- and Stressor-Related Disorder||Schizotypal (Personality) Disorder|Delusional Disorder|Brief Psychotic Disorder|Schizophreniform Disorder|Schizophrenia|Schizoaffective Disorder|Substance/Medication-Induced Psychotic Disorder|Psychotic Disorder Due to Another Medical Condition|Catatonia Associated With Another Mental Disorder (Catatonia Specifier)|Catatonic Disorder Due to Another Medical Condition|Unspecified Catatonia|Other Specified Schizophrenia Spectrum and Other Psychotic Disorder|Unspecified Schizophrenia Spectrum and Other Psychotic Disorder||Obsessive-Compulsive Disorder (OCD)|Body Dysmorphic Disorder|Hoarding Disorder|Trichotillomania (Hair-Pulling Disorder)|Excoriation (Skin-Picking) Disorder|Substance/Medication-Induced Obsessive-Compulsive and Related Disorder|Obsessive-Compulsive and Related Disorder Due to Another Medical Condition|Other Specified Obsessive-Compulsive and Related Disorder|Unspecified Obsessive-Compulsive and Related Disorder||Dissociative Identity Disorder|Dissociative Amnesia|Depersonalization/Derealization Disorder|Other Specified Dissociative Disorder|Unspecified Dissociative Disorder||Somatic Symptom Disorder|Illness Anxiety Disorder|Conversion Disorder (Functional Neurological Symptom Disorder)|Psychological Factors Affecting Other Medical Conditions|Factitious Disorder|Other Specified Somatic Symptom and Related Disorder|Unspecified Somatic Symptom and Related Disorder||Pica|Rumination Disorder|Avoidant/Restrictive Food Intake Disorder|Anorexia Nervosa|Bulimia Nervosa|Binge-Eating Disorder|Other Specified Feeding or Eating Disorder|Unspecified Feeding or Eating Disorder||Enuresis|Encopresis|Other Specified Elimination Disorder|Unspecified Elimination Disorder||Insomnia Disorder|Hypersomnolence Disorder|Narcolepsy|Obstructive Sleep Apnea Hypopnea|Central Sleep Apnea|Sleep-Related Hypoventilation|Circadian Rhythm Sleep-Wake Disorders|Non-Rapid Eye Movement Sleep Arousal Disorders|Nightmare Disorder|Rapid Eye Movement Sleep Behavior Disorder|Restless Legs Syndrome|Substance/Medication-Induced Sleep Disorder|Other Specified Insomnia Disorder|Unspecified Insomnia Disorder|Other Specified Hypersomnolence Disorder|Unspecified Hypersomnolence Disorder|Other Specified Sleep-Wake Disorder|Unspecified Sleep-Wake Disorder||Gender Dysphoria in Children|Gender Dysphoria in Adolescents and Adults|Other Specified Gender Dysphoria|Unspecified Gender Dysphoria||Delayed Ejaculation|Erectile Disorder|Female Orgasmic Disorder|Female Sexual Interest/Arousal Disorder|Genito-Pelvic Pain/Penetration Disorder|Male Hypoactive Sexual Desire Disorder|Premature (Early) Ejaculation|Substance/Medication-Induced Sexual Dysfunction|Other Specified Sexual Dysfunction|Unspecified Sexual Dysfunction||Oppositional Defiant Disorder|Intermittent Explosive Disorder|Conduct Disorder|Antisocial Personality Disorder|Pyromania|Kleptomania|Other Specified Disruptive, Impulse-Control, and Conduct Disorder|Unspecified Disruptive, Impulse-Control, and Conduct Disorder||Alcohol Use Disorder|Alcohol Intoxication|Alcohol Withdrawal|Caffeine Intoxication|Caffeine Withdrawal|Cannabis Use Disorder|Cannabis Intoxication|Cannabis Withdrawal|Phencyclidine Use Disorder|Other Hallucinogen Use Disorder|Phencyclidine Intoxication|Other Hallucinogen Intoxication|Hallucinogen Persisting Perception Disorder|Inhalant Use Disorder|Inhalant Intoxication|Opioid Use Disorder|Opioid Intoxication|Opioid Withdrawal|Sedative, Hypnotic, or Anxiolytic Use Disorder|Sedative, Hypnotic, or Anxiolytic Intoxication|Sedative, Hypnotic, or Anxiolytic Withdrawal|Stimulant Use Disorder|Stimulant Intoxication|Stimulant Withdrawal|Tobacco Use Disorder|Tobacco Withdrawal|Other (or Unknown) Substance Use Disorder|Other (or Unknown) Substance Intoxication|Other (or Unknown) Substance Withdrawal|Gambling Disorder||Delirium|Major Neurocognitive Disorder Due to Alzheimer's Disease|Mild Neurocognitive Disorder Due to Alzheimer's Disease|Major Frontotemporal Neurocognitive Disorder|Mild Frontotemporal Neurocognitive Disorder|Major Neurocognitive Disorder With Lewy Bodies|Mild Neurocognitive Disorder With Lewy Bodies|Major Vascular Neurocognitive Disorder|Mild Vascular Neurocognitive Disorder|Major Neurocognitive Disorder Due to Traumatic Brain Injury|Mild Neurocognitive Disorder Due to Traumatic Brain Injury|Substance/Medication-Induced Major Neurocognitive Disorder|Substance/Medication-Induced Mild Neurocognitive Disorder|Major Neurocognitive Disorder Due to HIV Infection|Mild Neurocognitive Disorder Due to HIV Infection|Major Neurocognitive Disorder Due to Prion Disease|Mild Neurocognitive Disorder Due to Prion Disease|Major Neurocognitive Disorder Due to Parkinson's Disease|Mild Neurocognitive Disorder Due to Parkinson's Disease|Major Neurocognitive Disorder Due to Huntington's Disease|Mild Neurocognitive Disorder Due to Huntington's Disease|Major Neurocognitive Disorder Due to Another Medical Condition|Mild Neurocognitive Disorder Due to Another Medical Condition|Major Neurocognitive Disorder Due to Multiple Etiologies|Mild Neurocognitive Disorder Due to Multiple Etiologies|Unspecified Neurocognitive Disorder||Intellectual Disability (Intellectual Developmental Disorder)|Global Developmental Delay|Unspecified Intellectual Disability (Intellectual Developmental Disorder)|Language Disorder|Speech Sound Disorder|Childhood-Onset Fluency Disorder (Stuttering)|Social (Pragmatic) Communication Disorder|Unspecified Communication Disorder|Autism Spectrum Disorder|Attention-Deficit/Hyperactivity Disorder|Other Specified Attention-Deficit/Hyperactivity Disorder|Unspecified Attention-Deficit/Hyperactivity Disorder|Specific Learning Disorder|Developmental Coordination Disorder|Stereotypic Movement Disorder|Tic Disorders|Other Specified Tic Disorder|Unspecified Tic Disorder|Other Specified Neurodevelopmental Disorder|Unspecified Neurodevelopmental Disorder||Paranoid Personality Disorder|Schizoid Personality Disorder|Schizotypal Personality Disorder|Antisocial Personality Disorder|Borderline Personality Disorder|Histrionic Personality Disorder|Narcissistic Personality Disorder|Avoidant Personality Disorder|Dependent Personality Disorder|Obsessive-Compulsive Personality Disorder|Other Specified Personality Disorder|Unspecified Personality Disorder||Voyeuristic Disorder|Exhibitionistic Disorder|Frotteuristic Disorder|Sexual Masochism Disorder|Sexual Sadism Disorder|Pedophilic Disorder|Fetishistic Disorder|Transvestic Disorder|Other Specified Paraphilic Disorder|Unspecified Paraphilic Disorder||Neuroleptic-Induced Parkinsonism|Other Medication-Induced Parkinsonism|Neuroleptic Malignant Syndrome|Medication-Induced Acute Dystonia|Medication-Induced Acute Akathisia|Tardive Dyskinesia|Tardive Dystonia|Tardive Akathisia|Medication-Induced Postural Tremor|Other Medication-Induced Movement Disorder|Antidepressant Discontinuation Syndrome|Other Adverse Effect of Medication"]
- [comment memo="DIAGNOSIS 2" memo_size="large"][select name="variable_dx2" value="|Major Depressive Disorder, Single Episode|Major Depressive Disorder, Recurrent Episode|Persistent Depressive Disorder (Dysthymia)|Disruptive Mood Dysregulation Disorder|Premenstrual Dysphoric Disorder|Substance/Medication-Induced Depressive Disorder|Depressive Disorder Due to Another Medical Condition|Other Specified Depressive Disorder|Unspecified Depressive Disorder||Bipolar I Disorder|Bipolar II Disorder|Cyclothymic Disorder|Substance/Medication-Induced Bipolar and Related Disorder|Bipolar and Related Disorder Due to Another Medical Condition|Other Specified Bipolar and Related Disorder|Unspecified Bipolar and Related Disorder||Separation Anxiety Disorder|Selective Mutism|Specific Phobia|Social Anxiety Disorder (Social Phobia)|Panic Disorder|Panic Attack (Specifier)|Agoraphobia|Generalized Anxiety Disorder|Substance/Medication-Induced Anxiety Disorder|Anxiety Disorder Due to Another Medical Condition|Other Specified Anxiety Disorder|Unspecified Anxiety Disorder||Reactive Attachment Disorder|Disinhibited Social Engagement Disorder|Posttraumatic Stress Disorder (PTSD)|Acute Stress Disorder|Adjustment Disorders|Other Specified Trauma- and Stressor-Related Disorder|Unspecified Trauma- and Stressor-Related Disorder||Schizotypal (Personality) Disorder|Delusional Disorder|Brief Psychotic Disorder|Schizophreniform Disorder|Schizophrenia|Schizoaffective Disorder|Substance/Medication-Induced Psychotic Disorder|Psychotic Disorder Due to Another Medical Condition|Catatonia Associated With Another Mental Disorder (Catatonia Specifier)|Catatonic Disorder Due to Another Medical Condition|Unspecified Catatonia|Other Specified Schizophrenia Spectrum and Other Psychotic Disorder|Unspecified Schizophrenia Spectrum and Other Psychotic Disorder||Obsessive-Compulsive Disorder (OCD)|Body Dysmorphic Disorder|Hoarding Disorder|Trichotillomania (Hair-Pulling Disorder)|Excoriation (Skin-Picking) Disorder|Substance/Medication-Induced Obsessive-Compulsive and Related Disorder|Obsessive-Compulsive and Related Disorder Due to Another Medical Condition|Other Specified Obsessive-Compulsive and Related Disorder|Unspecified Obsessive-Compulsive and Related Disorder||Dissociative Identity Disorder|Dissociative Amnesia|Depersonalization/Derealization Disorder|Other Specified Dissociative Disorder|Unspecified Dissociative Disorder||Somatic Symptom Disorder|Illness Anxiety Disorder|Conversion Disorder (Functional Neurological Symptom Disorder)|Psychological Factors Affecting Other Medical Conditions|Factitious Disorder|Other Specified Somatic Symptom and Related Disorder|Unspecified Somatic Symptom and Related Disorder||Pica|Rumination Disorder|Avoidant/Restrictive Food Intake Disorder|Anorexia Nervosa|Bulimia Nervosa|Binge-Eating Disorder|Other Specified Feeding or Eating Disorder|Unspecified Feeding or Eating Disorder||Enuresis|Encopresis|Other Specified Elimination Disorder|Unspecified Elimination Disorder||Insomnia Disorder|Hypersomnolence Disorder|Narcolepsy|Obstructive Sleep Apnea Hypopnea|Central Sleep Apnea|Sleep-Related Hypoventilation|Circadian Rhythm Sleep-Wake Disorders|Non-Rapid Eye Movement Sleep Arousal Disorders|Nightmare Disorder|Rapid Eye Movement Sleep Behavior Disorder|Restless Legs Syndrome|Substance/Medication-Induced Sleep Disorder|Other Specified Insomnia Disorder|Unspecified Insomnia Disorder|Other Specified Hypersomnolence Disorder|Unspecified Hypersomnolence Disorder|Other Specified Sleep-Wake Disorder|Unspecified Sleep-Wake Disorder||Gender Dysphoria in Children|Gender Dysphoria in Adolescents and Adults|Other Specified Gender Dysphoria|Unspecified Gender Dysphoria||Delayed Ejaculation|Erectile Disorder|Female Orgasmic Disorder|Female Sexual Interest/Arousal Disorder|Genito-Pelvic Pain/Penetration Disorder|Male Hypoactive Sexual Desire Disorder|Premature (Early) Ejaculation|Substance/Medication-Induced Sexual Dysfunction|Other Specified Sexual Dysfunction|Unspecified Sexual Dysfunction||Oppositional Defiant Disorder|Intermittent Explosive Disorder|Conduct Disorder|Antisocial Personality Disorder|Pyromania|Kleptomania|Other Specified Disruptive, Impulse-Control, and Conduct Disorder|Unspecified Disruptive, Impulse-Control, and Conduct Disorder||Alcohol Use Disorder|Alcohol Intoxication|Alcohol Withdrawal|Caffeine Intoxication|Caffeine Withdrawal|Cannabis Use Disorder|Cannabis Intoxication|Cannabis Withdrawal|Phencyclidine Use Disorder|Other Hallucinogen Use Disorder|Phencyclidine Intoxication|Other Hallucinogen Intoxication|Hallucinogen Persisting Perception Disorder|Inhalant Use Disorder|Inhalant Intoxication|Opioid Use Disorder|Opioid Intoxication|Opioid Withdrawal|Sedative, Hypnotic, or Anxiolytic Use Disorder|Sedative, Hypnotic, or Anxiolytic Intoxication|Sedative, Hypnotic, or Anxiolytic Withdrawal|Stimulant Use Disorder|Stimulant Intoxication|Stimulant Withdrawal|Tobacco Use Disorder|Tobacco Withdrawal|Other (or Unknown) Substance Use Disorder|Other (or Unknown) Substance Intoxication|Other (or Unknown) Substance Withdrawal|Gambling Disorder||Delirium|Major Neurocognitive Disorder Due to Alzheimer's Disease|Mild Neurocognitive Disorder Due to Alzheimer's Disease|Major Frontotemporal Neurocognitive Disorder|Mild Frontotemporal Neurocognitive Disorder|Major Neurocognitive Disorder With Lewy Bodies|Mild Neurocognitive Disorder With Lewy Bodies|Major Vascular Neurocognitive Disorder|Mild Vascular Neurocognitive Disorder|Major Neurocognitive Disorder Due to Traumatic Brain Injury|Mild Neurocognitive Disorder Due to Traumatic Brain Injury|Substance/Medication-Induced Major Neurocognitive Disorder|Substance/Medication-Induced Mild Neurocognitive Disorder|Major Neurocognitive Disorder Due to HIV Infection|Mild Neurocognitive Disorder Due to HIV Infection|Major Neurocognitive Disorder Due to Prion Disease|Mild Neurocognitive Disorder Due to Prion Disease|Major Neurocognitive Disorder Due to Parkinson's Disease|Mild Neurocognitive Disorder Due to Parkinson's Disease|Major Neurocognitive Disorder Due to Huntington's Disease|Mild Neurocognitive Disorder Due to Huntington's Disease|Major Neurocognitive Disorder Due to Another Medical Condition|Mild Neurocognitive Disorder Due to Another Medical Condition|Major Neurocognitive Disorder Due to Multiple Etiologies|Mild Neurocognitive Disorder Due to Multiple Etiologies|Unspecified Neurocognitive Disorder||Intellectual Disability (Intellectual Developmental Disorder)|Global Developmental Delay|Unspecified Intellectual Disability (Intellectual Developmental Disorder)|Language Disorder|Speech Sound Disorder|Childhood-Onset Fluency Disorder (Stuttering)|Social (Pragmatic) Communication Disorder|Unspecified Communication Disorder|Autism Spectrum Disorder|Attention-Deficit/Hyperactivity Disorder|Other Specified Attention-Deficit/Hyperactivity Disorder|Unspecified Attention-Deficit/Hyperactivity Disorder|Specific Learning Disorder|Developmental Coordination Disorder|Stereotypic Movement Disorder|Tic Disorders|Other Specified Tic Disorder|Unspecified Tic Disorder|Other Specified Neurodevelopmental Disorder|Unspecified Neurodevelopmental Disorder||Paranoid Personality Disorder|Schizoid Personality Disorder|Schizotypal Personality Disorder|Antisocial Personality Disorder|Borderline Personality Disorder|Histrionic Personality Disorder|Narcissistic Personality Disorder|Avoidant Personality Disorder|Dependent Personality Disorder|Obsessive-Compulsive Personality Disorder|Other Specified Personality Disorder|Unspecified Personality Disorder||Voyeuristic Disorder|Exhibitionistic Disorder|Frotteuristic Disorder|Sexual Masochism Disorder|Sexual Sadism Disorder|Pedophilic Disorder|Fetishistic Disorder|Transvestic Disorder|Other Specified Paraphilic Disorder|Unspecified Paraphilic Disorder||Neuroleptic-Induced Parkinsonism|Other Medication-Induced Parkinsonism|Neuroleptic Malignant Syndrome|Medication-Induced Acute Dystonia|Medication-Induced Acute Akathisia|Tardive Dyskinesia|Tardive Dystonia|Tardive Akathisia|Medication-Induced Postural Tremor|Other Medication-Induced Movement Disorder|Antidepressant Discontinuation Syndrome|Other Adverse Effect of Medication"]
-  [comment memo="DIAGNOSIS 3" memo_size="large"][select name="variable_dx3" value="|Major Depressive Disorder, Single Episode|Major Depressive Disorder, Recurrent Episode|Persistent Depressive Disorder (Dysthymia)|Disruptive Mood Dysregulation Disorder|Premenstrual Dysphoric Disorder|Substance/Medication-Induced Depressive Disorder|Depressive Disorder Due to Another Medical Condition|Other Specified Depressive Disorder|Unspecified Depressive Disorder||Bipolar I Disorder|Bipolar II Disorder|Cyclothymic Disorder|Substance/Medication-Induced Bipolar and Related Disorder|Bipolar and Related Disorder Due to Another Medical Condition|Other Specified Bipolar and Related Disorder|Unspecified Bipolar and Related Disorder||Separation Anxiety Disorder|Selective Mutism|Specific Phobia|Social Anxiety Disorder (Social Phobia)|Panic Disorder|Panic Attack (Specifier)|Agoraphobia|Generalized Anxiety Disorder|Substance/Medication-Induced Anxiety Disorder|Anxiety Disorder Due to Another Medical Condition|Other Specified Anxiety Disorder|Unspecified Anxiety Disorder||Reactive Attachment Disorder|Disinhibited Social Engagement Disorder|Posttraumatic Stress Disorder (PTSD)|Acute Stress Disorder|Adjustment Disorders|Other Specified Trauma- and Stressor-Related Disorder|Unspecified Trauma- and Stressor-Related Disorder||Schizotypal (Personality) Disorder|Delusional Disorder|Brief Psychotic Disorder|Schizophreniform Disorder|Schizophrenia|Schizoaffective Disorder|Substance/Medication-Induced Psychotic Disorder|Psychotic Disorder Due to Another Medical Condition|Catatonia Associated With Another Mental Disorder (Catatonia Specifier)|Catatonic Disorder Due to Another Medical Condition|Unspecified Catatonia|Other Specified Schizophrenia Spectrum and Other Psychotic Disorder|Unspecified Schizophrenia Spectrum and Other Psychotic Disorder||Obsessive-Compulsive Disorder (OCD)|Body Dysmorphic Disorder|Hoarding Disorder|Trichotillomania (Hair-Pulling Disorder)|Excoriation (Skin-Picking) Disorder|Substance/Medication-Induced Obsessive-Compulsive and Related Disorder|Obsessive-Compulsive and Related Disorder Due to Another Medical Condition|Other Specified Obsessive-Compulsive and Related Disorder|Unspecified Obsessive-Compulsive and Related Disorder||Dissociative Identity Disorder|Dissociative Amnesia|Depersonalization/Derealization Disorder|Other Specified Dissociative Disorder|Unspecified Dissociative Disorder||Somatic Symptom Disorder|Illness Anxiety Disorder|Conversion Disorder (Functional Neurological Symptom Disorder)|Psychological Factors Affecting Other Medical Conditions|Factitious Disorder|Other Specified Somatic Symptom and Related Disorder|Unspecified Somatic Symptom and Related Disorder||Pica|Rumination Disorder|Avoidant/Restrictive Food Intake Disorder|Anorexia Nervosa|Bulimia Nervosa|Binge-Eating Disorder|Other Specified Feeding or Eating Disorder|Unspecified Feeding or Eating Disorder||Enuresis|Encopresis|Other Specified Elimination Disorder|Unspecified Elimination Disorder||Insomnia Disorder|Hypersomnolence Disorder|Narcolepsy|Obstructive Sleep Apnea Hypopnea|Central Sleep Apnea|Sleep-Related Hypoventilation|Circadian Rhythm Sleep-Wake Disorders|Non-Rapid Eye Movement Sleep Arousal Disorders|Nightmare Disorder|Rapid Eye Movement Sleep Behavior Disorder|Restless Legs Syndrome|Substance/Medication-Induced Sleep Disorder|Other Specified Insomnia Disorder|Unspecified Insomnia Disorder|Other Specified Hypersomnolence Disorder|Unspecified Hypersomnolence Disorder|Other Specified Sleep-Wake Disorder|Unspecified Sleep-Wake Disorder||Gender Dysphoria in Children|Gender Dysphoria in Adolescents and Adults|Other Specified Gender Dysphoria|Unspecified Gender Dysphoria||Delayed Ejaculation|Erectile Disorder|Female Orgasmic Disorder|Female Sexual Interest/Arousal Disorder|Genito-Pelvic Pain/Penetration Disorder|Male Hypoactive Sexual Desire Disorder|Premature (Early) Ejaculation|Substance/Medication-Induced Sexual Dysfunction|Other Specified Sexual Dysfunction|Unspecified Sexual Dysfunction||Oppositional Defiant Disorder|Intermittent Explosive Disorder|Conduct Disorder|Antisocial Personality Disorder|Pyromania|Kleptomania|Other Specified Disruptive, Impulse-Control, and Conduct Disorder|Unspecified Disruptive, Impulse-Control, and Conduct Disorder||Alcohol Use Disorder|Alcohol Intoxication|Alcohol Withdrawal|Caffeine Intoxication|Caffeine Withdrawal|Cannabis Use Disorder|Cannabis Intoxication|Cannabis Withdrawal|Phencyclidine Use Disorder|Other Hallucinogen Use Disorder|Phencyclidine Intoxication|Other Hallucinogen Intoxication|Hallucinogen Persisting Perception Disorder|Inhalant Use Disorder|Inhalant Intoxication|Opioid Use Disorder|Opioid Intoxication|Opioid Withdrawal|Sedative, Hypnotic, or Anxiolytic Use Disorder|Sedative, Hypnotic, or Anxiolytic Intoxication|Sedative, Hypnotic, or Anxiolytic Withdrawal|Stimulant Use Disorder|Stimulant Intoxication|Stimulant Withdrawal|Tobacco Use Disorder|Tobacco Withdrawal|Other (or Unknown) Substance Use Disorder|Other (or Unknown) Substance Intoxication|Other (or Unknown) Substance Withdrawal|Gambling Disorder||Delirium|Major Neurocognitive Disorder Due to Alzheimer's Disease|Mild Neurocognitive Disorder Due to Alzheimer's Disease|Major Frontotemporal Neurocognitive Disorder|Mild Frontotemporal Neurocognitive Disorder|Major Neurocognitive Disorder With Lewy Bodies|Mild Neurocognitive Disorder With Lewy Bodies|Major Vascular Neurocognitive Disorder|Mild Vascular Neurocognitive Disorder|Major Neurocognitive Disorder Due to Traumatic Brain Injury|Mild Neurocognitive Disorder Due to Traumatic Brain Injury|Substance/Medication-Induced Major Neurocognitive Disorder|Substance/Medication-Induced Mild Neurocognitive Disorder|Major Neurocognitive Disorder Due to HIV Infection|Mild Neurocognitive Disorder Due to HIV Infection|Major Neurocognitive Disorder Due to Prion Disease|Mild Neurocognitive Disorder Due to Prion Disease|Major Neurocognitive Disorder Due to Parkinson's Disease|Mild Neurocognitive Disorder Due to Parkinson's Disease|Major Neurocognitive Disorder Due to Huntington's Disease|Mild Neurocognitive Disorder Due to Huntington's Disease|Major Neurocognitive Disorder Due to Another Medical Condition|Mild Neurocognitive Disorder Due to Another Medical Condition|Major Neurocognitive Disorder Due to Multiple Etiologies|Mild Neurocognitive Disorder Due to Multiple Etiologies|Unspecified Neurocognitive Disorder||Intellectual Disability (Intellectual Developmental Disorder)|Global Developmental Delay|Unspecified Intellectual Disability (Intellectual Developmental Disorder)|Language Disorder|Speech Sound Disorder|Childhood-Onset Fluency Disorder (Stuttering)|Social (Pragmatic) Communication Disorder|Unspecified Communication Disorder|Autism Spectrum Disorder|Attention-Deficit/Hyperactivity Disorder|Other Specified Attention-Deficit/Hyperactivity Disorder|Unspecified Attention-Deficit/Hyperactivity Disorder|Specific Learning Disorder|Developmental Coordination Disorder|Stereotypic Movement Disorder|Tic Disorders|Other Specified Tic Disorder|Unspecified Tic Disorder|Other Specified Neurodevelopmental Disorder|Unspecified Neurodevelopmental Disorder||Paranoid Personality Disorder|Schizoid Personality Disorder|Schizotypal Personality Disorder|Antisocial Personality Disorder|Borderline Personality Disorder|Histrionic Personality Disorder|Narcissistic Personality Disorder|Avoidant Personality Disorder|Dependent Personality Disorder|Obsessive-Compulsive Personality Disorder|Other Specified Personality Disorder|Unspecified Personality Disorder||Voyeuristic Disorder|Exhibitionistic Disorder|Frotteuristic Disorder|Sexual Masochism Disorder|Sexual Sadism Disorder|Pedophilic Disorder|Fetishistic Disorder|Transvestic Disorder|Other Specified Paraphilic Disorder|Unspecified Paraphilic Disorder||Neuroleptic-Induced Parkinsonism|Other Medication-Induced Parkinsonism|Neuroleptic Malignant Syndrome|Medication-Induced Acute Dystonia|Medication-Induced Acute Akathisia|Tardive Dyskinesia|Tardive Dystonia|Tardive Akathisia|Medication-Induced Postural Tremor|Other Medication-Induced Movement Disorder|Antidepressant Discontinuation Syndrome|Other Adverse Effect of Medication"]
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ASSESSMENT AND RESPONSE TO TREATMENT:
 
Case of a [var name="variable_age"] y/o [var name="variable_gender"] with PMHx of [var name="variable_medhx"], [var name="variable_pastdx"], who arrived to ED due to  [var name="variable_admireason1"] and transferred to the MH inpatient unit under [comment memo="BAKER ACT" memo_size="large"][select name="variable_ba" value="Voluntary Baker Act|Involuntary Baker Act"]. Veteran has history of [var name="priorhospi"] and [var name="suicideattempts"]. Lab work was [comment memo="LABS" memo_size="large"][text name="variable_labs" default="significant for"].    ECG showed [var name="variable_ecgfind"], QTc [var name="variable_qtc"]. In the ED, patient  [comment memo="ED MEDS" memo_size="large"][text name="variable_edmeds" default="received" size=100].Patient [var name="variable_SI"][var name="variable_hallu"]. During today’s interview, the patient's behavior was [var name="variable_behavior"]; affect [var name="variable_affect"]; thought process was [var name="variable_process"]; thought content showed [var name="variable_content"]. Based on today’s evaluation, patient meets diagnostic criteria for [comment memo="DIAGNOSIS" memo_size="large"] [select name="variable_criteria" value="Major Depressive Disorder due to symptoms of depressed mood most of the day, nearly every day for more than 2 weeks, along with little pleasure in doing things, hopelessness, helplessness, lack of energy, poor concentration, changes in appetite, psychomotor retardation and poor sleep which greatly impact patient’s everyday life|Generalized Anxiety Disorder due to symptoms of anxiety about multiple aspects  patient’s life and difficulty controlling worry, nerly everyday, for a minimum of 6 months, along with anxiety;  nervousness, restlessness, muscle tension, difficulty concentrating, irritability and sleep disturbances|Social Anxiety Disorder, characterized by marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others, leading to significant avoidance and impairment in functioning|Adjustment Disorders, characterized by the development of emotional or behavioral symptoms in response to an identifiable stressor occurring within 3 months of the onset of the stressor, with the distress being out of proportion to the severity or intensity of the stressor and causing significant impairment in social, occupational, or other important areas of functioning|Bipolar I Disorder, which includes at least one manic episode  characterized by elevated mood, increased energy, and three or more symptoms such as grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, psychomotor agitation, or risky behaviors|Bipolar II Disorder, characterized by at least one hypomanic episode with elevated mood, increased energy, and symptoms like decreased need for sleep, talkativeness, or risky behaviors, along with one major depressive episode|Panic Disorder, characterized by recurrent unexpected panic attacks, which include symptoms like palpitations, sweating, trembling, shortness of breath, chest pain, nausea, dizziness, and fear of losing control or dying, along with persistent concern or behavior changes related to the attacks|Acute Stress Disorder, characterized by the development of severe anxiety, dissociation, and other symptoms that occur within one month after exposure to an extreme traumatic stressor, with the disturbance causing significant impairment in social, occupational, or other important areas of functioning|PTSD, characterized by exposure to a traumatic event, followed by persistent intrusive memories, avoidance of reminders, negative alterations in mood and cognition, and heightened arousal or reactivity, all lasting for more than one month and significantly impacting daily functioning|Schizophrenia, characterized by at least 6 months of delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms, with at least one being delusions, hallucinations, or disorganized speech, significantly impairing social or occupational functioning|Brief Psychotic Disorder, characterized by the sudden onset of psychotic symptoms such as delusions, hallucinations, disorganized speech, or grossly disorganized or catatonic behavior, lasting at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning|Schizoaffective Disorder, characterized by an uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms)|Delusional Disorder, characterized by the presence of one or more delusions for at least 1 month, with the absence of other psychotic symptoms, and behavior not obviously odd or bizarre, causing significant impairment in functioning or marked distress|Substance-Induced Mood Disorder, characterized by prominent mood disturbances, such as depression or elevated mood, directly related to the physiological effects of a substance, with symptoms emerging during or shortly after substance use or withdrawal, and not better explained by another mood disorder|Antisocial Personality Disorder, characterized by a pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, with symptoms such as repeated unlawful behavior, deceitfulness, impulsivity, irritability, aggressiveness, disregard for safety, consistent irresponsibility, and lack of remorse, causing significant impairment in social or occupational functioning|Borderline Personality Disorder, characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affects, along with marked impulsivity, beginning by early adulthood and present in a variety of contexts, leading to significant distress or impairment in functioning"].Plan is to [comment memo="MEDICATION PLAN" memo_size="large"][select name="variable_plan1" value="continue with the same dose of current medications, as they has shown  therapeutic benefit, effectively improving the patient’s symptoms|start trial of ______  to address ______ . Will continue the same dose of other medications, as they has shown therapeutic benefit|increase ______, as patient continues to experience residual symptoms despite the current dose|discontinue ______, as it has has proven ineffective in managing the patient's symptoms|decrease ______, as patient is experiencing dose-related side effects"]. Will    work    on    stabilization    of    medication    while    establishing    therapuetic    alliance    and    safe    discharge    planning.
 
 
Patient continues to meet criteria for inpatient psychiatric hospitalization due to [comment memo="INPATIENT CRITERIA" memo_size="large"][comment memo="InpatientCriteria"][checkbox name="variable_inpatientcriteria" value="Severe depressive symptoms|Manic or hypomanic symptoms|Delusions|Hallucinations|Suicidal ideations with plan or unwillingness to disclose|Homicidal ideations with plan or unwillingness to disclose|Disorganized behavior|Extreme paranoia|Non-suicidal self injury|Alcohol, sedative, anxiolytic, opiates withdrawal|Suicidal attempt (within last 48 hrs)|Homicidal attempt (within last 48 hrs)"].
 
-  Active interventions within last 24 hrs:  [comment memo="INTERVENTIONS" memo_size="large"][checkbox name="variable_interventions" value="Recent medication initiation or adjusment|Psychiatric PRN medications required at least 2 times in 24hrs|1:1 observation|Medical withdrawal management|Emergency treatment|ECT|Inpatient Baker Act petition filed|Restrains|Medical evaluation for:|Labs ordered"].
 
==============================================================================
PLAN:
 
- Medications to continue: [var name="variable_meds"]
 
- Medications to stop: N/A
 
- Medications to add: N/A
 
- Medications to change: N/A
 
- Order: [comment memo="ORDERS" memo_size="large"][select name="variable_orders" value="N/A|Labs: ______|EEG|Respiratory Panel|CT scan|Other: _____"]
 
- Protocol: [comment memo="PROTOCOL" memo_size="large"][select name="variable_protocol" value="N/A|CIWA|COWS"]
 
- Non-psychiatric Medications: Reviewed and issues addressed with medical team, as needed, education was provider regarding side effects, risks, and benefits of medications.
 
- Legal: [comment memo="BA STATUS" memo_size="large"][select name="variable_legal" value="Voluntary Baker Act|Involuntary Baker Act"]
 
- Observation status: [comment memo="OBSERVATION" memo_size="large"][select name="variable_obs" value="Q 15 min|close observation with safety companion|1:1"].
 
- Referrals to: [comment memo="REFERRALS" memo_size="large"][select name="variable_referral" value="N/A|Psychology|Medicine|Nutrition"]
 
- Anticipated discharge date: [comment memo="DISCHARGE" memo_size="large"][select name="variable_dc" value="TBD|tomorrow"]
 
- Disposition: [comment memo="DISPOSITION" memo_size="large"][select name="variable_dispo" value="TBD|private home|DOM|ALF|CLC"]
 
Veteran verbalized understanding and agreed with plan.
 
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PSYCHOTHERAPY:
 
- In addition to psychiatric assessment and intervention, psychotherapy was provided.
 
- Therapeutic technique/approach involved a Veteran-centered approach.
 
- Psychotherapeutic treatment provided: Motivational interviewing/Dialectical behavioral therapy
 
- Response to Psychotherapeutic Intervention: receptive
 
- Time spent in Psychotherapy: 20 minutes