MH Discharge Follow-up Note

Contact with patient made [checkbox value="Via telephone|face to face|via SMS|via Email"]

When asked to describe whats happened since discharge from hospital, the Pt reported:

[textarea cols=60 rows=20 default=""]

When asked about concerns or questions, the Pt repled:

[textarea cols=60 rows=20 default="No."]

When asked to described their medication plan, the Pt reported:
[textarea cols=60 rows=20 default="No."]

When asked about the next appointment with their GP, and their transport plans to attend this appointment, the Pt advised:

[textarea cols=60 rows=10 default=""]

When asked about current supports, the Pt reported:

[textarea cols=60 rows=10 default=""]

When asked whether your family member / carer has concerns or questions, the Pt reported:

[textarea cols=60 rows=10 default=""]

[checkbox name="cmh_appointment_status" value="The Pt is not currently Case Managed.|Community Mental Health appointment scheduled for:|Community Mental Health appointment not scheduled"]
[conditional field="cmh_appointment_status" condition="(cmh_appointment_status).is('Community Mental Health appointment scheduled for:')"] [textarea name="cmh_appointment_details" cols=60 rows=10 default="The Patient's next Community Mental Health appointment is:"] [/conditional]

When asked about supplemental interventions required for medication, the Pt replied:

[textarea cols=60 rows=10 default=""]

Patient supported to make follow-up appointments not already in place:

[textarea cols=60 rows=10 default=""]

[checkbox name="handover_status" value="Handover to key stakeholders was not required.|Handover to key stakeholders was completed:"] [conditional field="handover_status" condition="(handover_status).is('Handover to key stakeholders was completed:')"] [textarea name="handover_details" cols=60 rows=10 default=""] [/conditional]

Appointment cards were provided for [textarea cols=60 rows=10 default=""]

MSE

Pt is a [checkbox value="male|female"] [checkbox value="young adult|mid-aged adult|older adult|young teen|older teen|child"]. [checkbox value="Unable to rate attention to|Reasonable attention to|Little attention to|Meticiulous attention to"] grooming [checkbox value=",of average weight|,appears overweight|,looks underweight"]. 
Posture: [checkbox value="relaxed|rigid|ill-at-ease|stooped|confident|aggressive|tense|slumped|unable to rate"]
Movement: [checkbox value="unremarkable|odd / peculiar|slowed|repetitive|restless|agitated|tremorous|unable to rate"]
Attention: [checkbox value="no concerns - attended well|seemed unaware|inattentive|distractible|hyper-vigilant|scattered concentration|preoccupied|confused|focused on irrelevancies"]
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"]
Mood reported: [text default=""]
Affect observed: [checkbox value="euthymic|tearful|labile|restricted|blunted |flat|dysphoric|anxious|angry |apathetic|ashamed|prideful|sad|irritable|hostile|pessimistic|depressed|manic|euphoric|unable to rate"]
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|mute - unable to rate"]
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)|unable to rate"]
Orientation: [checkbox value="no concerns|AH reported|VH reported|poor judgement|poor reality testing|poor insight|complete denial|unable to rate"]
Stressors disclosed without prompting: [checkbox value="nil|self-esteem|parenting|mental illness Sx|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"]
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|unable to rate"].

[checkbox name="acute_concerns" value="Acute concerns not observed today.|Acute concerns were observed and were escalated to:"][conditional field="acute_concerns" condition="(acute_concerns).is('Acute concerns were observed and were escalated to:')"] [textarea cols=60 rows=10 default=""][/conditional]

[checkbox name="interventions" value="There were no intervention needs identified today.|Intervention needs were identified and transfer of care occured:"][conditional field="interventions" condition="(interventions).is('Intervention needs were identified and transfer of care occured:')"] [textarea cols=60 rows=10 default=""] [checkbox name="Family member informed|Carer informed[/conditional]

[checkbox name="acute_concerns" value="Acute concerns not observed today.|Acute concerns were observed and were escalated to"][conditional field="acute_concerns" condition="(acute_concerns).is('Acute concerns were observed and were escalated to')"] [textarea cols=60 rows=10 default=""] [checkbox value="Carer advised|Carer not advised|Carer could not be contacted|NOK contacted|NOK could not be contacted"] [/conditional]

Contact with patient made

When asked to describe whats happened since discharge from hospital, the Pt reported:



When asked about concerns or questions, the Pt repled:



When asked to described their medication plan, the Pt reported:


When asked about the next appointment with their GP, and their transport plans to attend this appointment, the Pt advised:



When asked about current supports, the Pt reported:



When asked whether your family member / carer has concerns or questions, the Pt reported:






When asked about supplemental interventions required for medication, the Pt replied:



Patient supported to make follow-up appointments not already in place:





Appointment cards were provided for


MSE

Pt is a . grooming .
Posture:
Movement:
Attention:
Engagement:
Mood reported:
Affect observed:
Speech:
Thinking:
Orientation:
Stressors disclosed without prompting:
Suicide risk: .



Sandbox Metrics: Structured Data Index 0.58, 41 form elements, 126 boilerplate words, 1 text boxes, 14 text areas, 20 checkboxes, 1 drop downs, 5 conditionals, 189 total clicks
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