CMH Discharge / Transfer3

VISIT INFORMATION

Dear Colleague,

Thank you for continuing the care of [text name default=""] who was recently discharged from Community Mental Health. I am writing to update you on this patients mental health status and current functioning.

On [textarea cols=40 rows=1 default="date"], [text name default="NAME"] was admitted to our service, for [select value="voluntary|involuntary"] outpatient treatment of: [checkbox value="Neurodevelopmental Disorder|Schizophrenia Spectrum Disorder|Bipolar Disorder|Depressive Disorder|Anxiety Disorder|Obsessive-Compulsive Disorder|Trauma and Stress Related Disorder|Dissociative Disorder|Somatic Complaint Disorder|Feeding and Eating disorder|Elimination Disorder|Sleep-wake Disorder|Sexual Dysfunction|Conduct Disorder|Substance Abuse Disorder|Neuro-Cognitive Disorder|Personality Disorder|Paraphilic Disorder"].

-- Other concerns identified at initial assessment --

[checkbox value="nil|symptoms associated with a mental illness|intrusive negative thoughts|physical illness|death of friend|death in the family|death of a partner|coping with poor health|coping with partners poor health|adjusting to stage of life|withdrawing from substances|personal upheaval|divorce|separation from partner|relationship problems|imprisonment|poverty|personal injury|marrital discord|dismissal from work|marital reconciliation|retirement|change in health of a family member|pregnancy|sexual difficulties|gain a new family member|business readjustment|change in financial status|arguments with others|mortgage|debt|work stress|child leaving home|trouble with in-laws|lack of achievement|partner's employment status|school starting|school ending|change in living conditions|revision of personal habits|trouble with the boss|trouble with parents|change in work hours|change in work conditions|change in residence|change in school|church|religion|change in social activities|money worries|change in sleep habits|change in family structure|change in eating habits|vacation|Holiday stress|legal problems|problems with the weather|academic underachievement|target of bullying|discord with teachers|stressful work schedule|under-employment|hazardous work conditions|exposure to toxins|inadequate housing|homelessness|discord with lodgers|discord with neighbours|discord with landlord|insufficient welfare support|low self-esteem|physical abuse|sexual abuse|emotional abuse|a traumatic experience|parental pressure|unusual parenting practices|discord with healthcare professional|legal problems|victim of crime|immigrant status|minority status|marginalisation|social withdrawal and isolation|unable to make friends"][textarea cols=80 rows=10 default=""]

As a patient of Community Mental Health, [text name default="NAME"] was provided with [checkbox value="psychiatric medication|case management|community treatment order|clozapine management|diagnostic clarification|psychological assessment|psychotherapy|liasing with medical services|education around substance misuse|liasing with legal justice services|responsing to patient crisis|mental state monitoring|welfare checks|coordinating multiple services|carer support and education|psychoeducation|encouraging D&A services|psychosocial support referral|peer support|referral to rehab services|NDIS application|housing support|employment support|support with specialist medical service|supportive counselling|carer support|group therapy|safeside counselling referral|Pt advocacy|liaising with trustee and guardian|treatment planning"] [textarea default=""]. 

Clinical Impression:

On discharge, the severity of [textarea cols=40 rows=1 default="diagnosis"] was assessed as: [select value="not at all ill|almost fully recovered|mildly ill|moderately ill|markedly ill|severely ill|among the most extremely ill patients"]; which, compared to the patient's condition on admission, I rate as: [select value="very much improved|much improved|minimally improved|no change|minimally worse|much worse|very much worse|unable to be assessed"].

RISK ASSESSMENT on DISCHARGE

-- Suicide --

The patients suicide risk state is [checkbox value="higher than|similar to|lower than"] their usual baseline of risk. 

The patients risk status is [checkbox value="higher than|similar to|lower than"] the general population, and [checkbox value="higher than|similar to|lower than"] other patients in our service setting.

Foreseeable changes in suicide risk: 

[textarea default="Nil"]

Available risk resources accessible to the Pt: 

[textarea default="Help line numbers, Acute Care Team, PRN meds, Friends, Family, Counsellor, Community Mental Health Clinician, Disability Support Worker, NGO Caseworker, Distraction strategies"]

-- Other Risk Concerns --

[textarea default="Nil"]

Discharge Medications: [textarea cols=80 rows=40 default=""].
 
Discharge plan: [checkbox value="provided patient the details of the expected time and date of discharge|established carer’s capability and willingness to assist|arranged for sufficient quantities of medication to last until the next consultation|checked that the patient understands the purpose, dosage, frequency and side-effects of the medication|discussed the expected recovery path and confirmed understanding|confirmed necessary follow-up appointments with the patient's healthcare provider|arranged travel assistance|provided details of the patient's medical follow-up appointments|provided contact details for community mental health services and follow up arrangements|provided contact details for private mental health services and follow up arrangements|educated the patient about signs of possible relapse and what to do|provided the patient with emergency contact numbers|provided the patient with a self-management plan (including coping strategies)|provided the patient with a crisis management plan|confirmed community support arrangements including referrals to other services / programs"]
[textarea cols=80 rows=40 default=""]

If you have any questions regarding this patient, please feel free to contact me.

Kind Regards,


CLINICIAN
ROLE
Community Mental health
TELEPHONE
 
SUMMARY of CARE

[checkbox value="psychiatric medication|case management|community treatment order|clozapine management|diagnostic clarification|psychological assessment|psychotherapy|liasing with medical services|education around substance misuse|liasing with legal justice services|responsing to patient crisis|mental state monitoring|welfare checks|coordinating multiple services|carer support and education|psychoeducation|encouraging D&A services|psychosocial support referral|peer support|referral to rehab services|NDIS application|housing support|employment support|support with specialist medical service|supportive counselling|carer support|group therapy|safeside counselling referral|Pt advocacy|liaising with trustee and guardian|treatment planning"] [textarea default=""]

FORMULATION

[text default="The patient"] is a [text default="age"] year-old [select value="female|male"] who lives [checkbox value="alone|with friends|with partner|with family|with strangers|with other patients"] in [checkbox value="private rental accomodation|a share house|a privately owned house|a privately owned unit|government housing|supported accomodation|a SIL house|an NGO supported home|a transient rough-sleeping lifestyle"] in [text default="SUBURB"]. Pt was referred for treatment by [checkbox value="the adult inpatient mental health unit|the acute care team|a GP|a private psychiatrist|family"]. [text default="NAME"] has been a patient of Community Mental Health since [text default="DATE"].

[text default="The patient"] presents with a diagnosis of [checkbox value="Neurodevelopmental Disorder|Schizophrenia Spectrum Disorder|Bipolar Disorder|Depressive Disorder|Anxiety Disorder|Obsessive-Compulsive Disorder|Trauma and Stress Related Disorder|Dissociative Disorder|Somatic Complaint Disorder|Feeding and Eating disorder|Elimination Disorder|Sleep-wake Disorder|Sexual Dysfunction|Conduct Disorder|Substance Abuse Disorder|Neuro-Cognitive Disorder|Personality Disorder|Paraphilic Disorder"] that includes symptoms of [checkbox value="overactive, aggressive, disruptive or agitated behaviour|non-accidental self-injury|problem drinking or drug-taking|mania|cognitive problems|problems associated with hallucinations and delusions|problems with depressed mood|phobias|anxiety|obsessive-compulsive disturbance|stress|dissociative experiences|somatoform concerns|eating difficulties|sleep disturbance|sexual dysfunction|problems with relationships|problems with activities of daily living|problems with living conditions|problems with occupation and activities"] [textarea default=""]

[checkbox name="prosu" value="Progress towards discharge is promoted by:"][conditional field="prosu" condition="(prosu).is('Progress towards discharge is promoted by:')"] [checkbox value="treatment responsiveness|reduction of symptoms|increased autonomy|remission of illness|Pts active role in recovery|connectedness to friends and family|problem-solving skills|coping skills|ability to adapt to change|a sense of purpose or meaning in life|good social skills|ability to manage feelings of anger|motivation towards education|motivated to work|good overall health|access to mental and physical health care|healthy fear of risky behaviours and pain|hope for the future and optimism|sobriety|medical compliance|sense of the importance of health and wellness|impulse control|strong sense of self-worth|internal locus of control|access to a variety of clinical interventions|help seeking behaviours|resiliency|a supportive partner|a supportive family|being a parent|strong relationships, particularly with family members|opportunities to participate in and contribute|living in a reasonably safe and stable environment|sense of responsibility and duty to others|being a pet owner|intolerant attitude towards deviant behaviour|above average intelligence|having good academic grades|having a positive social orientation|having highly developed social skills|having the ability to plan ahead|having realistic expectations for the future|being religious|being connected to family|being connected to supportive adults outside the immediate family|ability to discuss problems with others|sharing activities with friends and family|having the consistent presence of a suportive other|involvement in pro-social activities|having positive role models|having affective relationships which are strong, close and prosocially oriented|being committed to learning and self improvement|being committed to work|having high needs for achievement|having non-deviant peers|having peer groups that do not condone antisocial behaviour|involvement in pro-social activities|exposure to positive parenting practices"][textarea cols=80 rows=5 default=""][/conditional].

RISKS

Suicide Risk State: [checkbox value="higher than|similar to|lower than"] the Pts usual baseline of risk.

Suicide Risk Status: [checkbox value="higher than|similar to|lower than"] the general population, and [checkbox value="higher than|similar to|lower than"] other Pts in the current service setting.

Foreseeable changes in suicide risk: 

[textarea default=""]

Available resources immediately accessible to the Pt: 

[textarea default="Help line numbers, Acute Care Team, PRN meds, Friends, Family, Counsellor, Community Mental Health Clinician, Disability Support Worker, NGO Caseworker"]

Other known risks to be aware of:

[textarea default="None foreseeable, self-harm, violence, vulnerablity, absconding, harm to children, other"]

Diagnosis: [checkbox value="Neurodevelopmental Disorder|Schizophrenia Spectrum Disorder|Bipolar Disorder|Depressive Disorder|Anxiety Disorder|Obsessive-Compulsive Disorder|Trauma and Stress Related Disorder|Dissociative Disorder|Somatic Complaint Disorder|Feeding and Eating disorder|Elimination Disorder|Sleep-wake Disorder|Sexual Dysfunction|Conduct Disorder|Substance Abuse Disorder|Neuro-Cognitive Disorder|Personality Disorder|Paraphilic Disorder"] that includes symptoms of [checkbox value="overactive, aggressive, disruptive or agitated behaviour|non-accidental self-injury|problem drinking or drug-taking|mania|cognitive problems|problems associated with hallucinations and delusions|problems with depressed mood|phobias|anxiety|obsessive-compulsive disturbance|stress|dissociative experiences|somatoform concerns|eating difficulties|sleep disturbance|sexual dysfunction|problems with relationships|problems with activities of daily living|problems with living conditions|problems with occupation and activities"] [textarea default=""]

ISSUES IDENTIFIED AT ASSESSMENT

[checkbox name="acaperf" value="Academic;"][conditional field="acaperf" condition="(acaperf).is('Academic;')"] in particular, the patient [checkbox value="frequently fails tests|struggles to keep up with peers|complains that the subject matter is too difficult|asserts that extracurricular activities are interfering with academic performance|lacks order and system in study|is disorganized and careless|lacks neatness|is rarely/never prepared|does not seek help when appropriate|copies from peers|engages in cheating/plagiarism|has poor attendance"] [textarea cols=80 rows=5 default=""][/conditional]

[checkbox name="sofac" value="Social;"][conditional field="sofac" condition="(sofac).is('Social;')"] in particular, the patient [checkbox value="is a loner|relates poorly to others|tends to isolate|does not fit in|feels excluded by others|is easily influenced and highly suggestible|engages in risky activities with peers|verbally criticizes peers|verbally criticizes caregivers|starts conflict without provocation|bullies and attempts to control others|does not respect rights and property of others|does not participate in group activities|interacts inappropriately with peers|is sexually inappropriate|is noncompliant with reasonable requests|frequently resists and disobeys authority|refuses to complete work assignments|does not follow rules and procedures|is socically disruptive|engages in attention seeking behaviours|is overly demanding of attention from others|has frequent tantrums in groups|frequently acts the clown|plays pranks on others|is overly dependent on others|timid/shy/dependent/anxiety-prone|is not accepted by others||does not sustain friendships|is an object of scorn/ridicule|is scapegoated/picked on|does not defend self when attacked|ostracized|social isolation|social withdrawal"] [textarea cols=80 rows=5 default=""][/conditional] 

[checkbox name="conduct" value="Conduct;"][conditional field="conduct" condition="(conduct).is('Conduct;')"] in particular, the patient [checkbox value="is verbally aggressive|frequently interrupts|starts fights|purposely agitates/disturbs/disrupts others|bullies and intimidates|frequently teases|attempts to manipulate|is overactive|is frequently inappropriate|cannot sit still and is generally restless|has numerous disciplinary offences|is malicious|is cold and calculating|lacks empathy and warmth|is cruel and punitive|has little respect for authority|is generally considered a troublemaker|is aggressive and generally violent|is destructive of own/others property|initiates physical fights|hits caregivers|is antagonistic|is frequently disobedient|is negativistic|is oppositional|is arguementative|talks back/mouthy|is defiant of authority|lies in regard to chores/homework/
house rules|complies only when threatened|is stubborn|is immature|demonstrates poor judgment|does not take responsibility for mistakes|does not own their behavior or consequences|demonstrates mutism|is prejudiced|is bigoted|insults others|vandalises|engages in hate crimes|lacks respect for authority|dares and provokes others|acts out|uses obscenities|has temper tantrums|falls to floor and tantrums|bangs head|has breath holding episodes|throws objects|screams|weeps|is generally destructive"]. [textarea cols=80 rows=5 default=""][/conditional]

[checkbox name="cogfac" value="Cognitive;"][conditional field="cogfac" condition="(cogfac).is('Cognitive;')"] in particular, the patient[checkbox value="is highly distractible|is hyperactive|is inattentive|handles novel situations poorly|lacks foresight|has low frustration tolerance|is easily confused|is unable to understand tasks|frequently daydreams|has poor concentration|is averse to change|is excessively concrete|has an inflexible and rigid thinking style|has unusual and extreme beliefs|appears intellectually delayed|is often confused and unable to accept guidance"]. [textarea cols=80 rows=5 default=""][/conditional]

[checkbox name="motdif" value="Motivational;"][conditional field="motdif" condition="(motdif).is('Motivational;')"] in particular, the patient [checkbox name="motdif" value="does not try hard with difficult tasks|generally makes little effort|is content to coast along|has the ability to do better work but lacks interest|generally shows no interest in the subject matter|does not persevere with most tasks|always needs great encouragement to complete work|gives up at first sign of difficulty|has low frustration tolerance|does not seem to pay attention|frequently daydreams|always seems preoccupied|is slow to respond|does not complete work assignments|does not make up for lost time|turns in assignments late|is careless with work|does not spend enough time on important tasks|copies from others|comes to class without necessary work materials|is frequently forgetful|misses excessive days|is known for frequent absenteeism|is always tardy|cuts classes|avoids work|is frequently truant|avoids school|refuses to attend school|refuses to attend work"] [textarea cols=80 rows=5 default=""][/conditional]

[checkbox name="becon" value="Behavioural;"][conditional field="becon" condition="(becon).is('Behavioural;')"] in particular, the patient [checkbox value="engages in alcohol/drug/substance abuse|has encopresis|has enuresis|engages in fire setting|engages in hypochondriasis|is frequently overactive and restless|engages in self injurious behaviour|hits others|bites others|engages in head banging|has a sexual preoccupation|engages in public masturbation|demonstrates inappropriate sexual behaviors|is frequently obscene|swears|makes sexualized gestures and remarks|exhibits genitals/disrobes/public nudity|wears provocative clothing|demonstrates molestation concerns|threatens others|touches others|fondles/rubs against others|engages in battery|has had forced sexual intercourse|is assaultative|has raped|threatens others|is slow moving|is slow to respond|lethargy|hypoactive|restless|fidgets|out of seat|impulsive|hyperactive/overactive|speech difficulties|thumb sucking|rocking|stereotyped movements|tics|noise or word productions|violence/aggression"] [textarea cols=80 rows=5 default=""][/conditional]

[checkbox name="afcon" value="Affect;"][conditional field="afcon" condition="(afcon).is('Affect;')"] in particular, the patient experiences [checkbox value="anxiety|fears|phobias|nervous habits|avoidance of particular certain things/actions/situations|anger|irritability|outbursts/rage/tantrums/meltdowns|tearfulness|sulking|whines|hurt feelings|low moods|feelings of  flatness|joyless|depressed|sad|unhappy|cries|feels hurt|has low energy|is easy fatigued|apathy|withdrawn|ashamed|guilty|suicidal|has limited range of emotions|expresses only high-intensity feelings|emotionally overactive|histrionic|dramatizes|plays the victim"] [textarea cols=80 rows=5 default="and other affect difficulties"][/conditional]

DISABILITY ISSUES

[checkbox name="comms" value="Understanding and Communicating"][conditional field="comms" condition="(comms).is('Understanding and Communicating')"], in particular: [checkbox value="concentrating|remembering|solving every day problems|learning a new task|understanding verbal communication|initiating and maintaining a conversation"][/conditional].

[checkbox name="gar" value="Getting around"][conditional field="gar" condition="(gar).is('Getting around')"], in particular: [checkbox value="standing for longer than 30 minutes|standing up|moving around the home|getting out of the home|walking distances greater than 1km"][/conditional].

[checkbox name="selc" value="Self-care"][conditional field="selc" condition="(selc).is('Self-care')"], in particular: [checkbox value="washing the whole body|getting dressed|eating|being alone for a few days"][/conditional].

[checkbox name="lifea" value="Life activities"][conditional field="lifea" condition="(lifea).is('Life activities')"], in particular: [checkbox value="managing a household|doing house hold tasks well|completing housework|completing housework in a timely manner|attending work|attending school|completing work tasks adequately|completing school tasks adequately|getting all work done|getting all work done in a timely manner"][/conditional].

[checkbox name="partin" value="Participation in society"][conditional field="partin" condition="(partin).is('Participation in society')"], in particular: [checkbox value="problems joining in community activities|problems because of barriers in the world|problems living with dignity due to the attitudes of others|time spend managing a health condition|Emotional impact of a health condition|impact of a health condition on finances|impact of health condition on family|problems doing things autonomously for relaxation or pleasure"][/conditional].

Communication Issues: [textarea cols=30 rows=1 default="Nil identified"]

MEDICATIONS

Discharge Medication: [textarea cols=40 rows=30 default="nil"]

MH Medications Recently Ceased: [textarea cols=40 rows=30 default="not reported"]

Allergies and Adverse Reactions: [textarea cols=80 rows=5 default="nil known"]

RESULTS REVIEW

HoNOS:

[checkbox value="No issues of note|Behavioural disturbance|Non-accidental self injury|Problem drinking or drug use|Cognitive problems|Problems related to physical illness or disability|Problems associated with hallucinations and delusions
|Problems associated with depressive symptoms|Other mental and behavioural problems|Problems with social or supportive relationships|Problems with activities of daily living|Overall problems with living conditions|Problems with work and leisure activities and the quality of the daytime environment"]. [textarea cols=40 rows=5 default=""]

Physical Investigations: [textarea cols=80 rows=5 default="N/A"]

Other Results: [textarea cols=80 rows=5 default="N/A"]

DISCHARGE INFORMATION
 
Discharge plan: [checkbox value="provided patient name the details of the expected time and date of discharge|established carer’s capability and willingness to assist|arranged for sufficient quantities of medication to last until the next consultation|checked that the patient understands the purpose, dosage, frequency and side-effects of their medication|discussed the expected recovery path and confirmed understanding|confirmed necessary follow-up appointments with the patient's healthcare provider|arranged travel assistance|provided details of the patient's medical follow-up appointments|provided contact details for community mental health services and follow up arrangements|provided contact details for private mental health services and follow up arrangements|educated the patient about signs of possible relapse and what to do|provided the patient with emergency contact numbers|provided the patient with a self-management plan (including coping strategies)|provided the patient with a crisis management plan|confirmed community support arrangements including referrals to other services / programs"] [textarea cols=40 rows=2 default=""]

Legal Status: [comment memo="choose one Legal Status"][checkbox value="Ambulatory - Voluntary Mental Health Client|Ambulatory - CTO|Ambulatory - Other|Forensic Patient|Forensic - CTO|No Act Applies|Other|Not known|Voluntary|Involuntary"].

Trustee and Guardian details: [textarea cols=40 rows=2 default="N/A"]

Guardianship details: [textarea cols=40 rows=2 default="N/A"]

CTO details: [textarea cols=40 rows=2 default="N/A"]

Involuntary Patient Order details: [textarea cols=40 rows=2 default="N/A"]

Forensic Patient status details: [textarea cols=40 rows=2 default="N/A"]

Other Legal Status details: [textarea cols=40 rows=2 default="N/A"]

Appointments on Discharge: [checkbox value="Nil|Private Psychiatrist|New Service Case Manager|GP|Out of State Mental Health Service"] [textarea cols=40 rows=2 default=""]

Other Services Involved: [textarea cols=80 rows=2 default="None"]

Recommended follow up: [textarea cols=80 rows=2 default="Recommended patient name follow up with their GP"]

Performed by: [textarea cols=80 rows=2 default="N/A"]

Copies to: [textarea cols=80 rows=2 default="Patient's GP"]
VISIT INFORMATION

Dear Colleague,

Thank you for continuing the care of who was recently discharged from Community Mental Health. I am writing to update you on this patients mental health status and current functioning.

On
, was admitted to our service, for outpatient treatment of: .

-- Other concerns identified at initial assessment --



As a patient of Community Mental Health, was provided with
.

Clinical Impression:

On discharge, the severity of
was assessed as: ; which, compared to the patient's condition on admission, I rate as: .

RISK ASSESSMENT on DISCHARGE

-- Suicide --

The patients suicide risk state is their usual baseline of risk.

The patients risk status is the general population, and other patients in our service setting.

Foreseeable changes in suicide risk:



Available risk resources accessible to the Pt:



-- Other Risk Concerns --



Discharge Medications:
.

Discharge plan:


If you have any questions regarding this patient, please feel free to contact me.

Kind Regards,


CLINICIAN
ROLE
Community Mental health
TELEPHONE

SUMMARY of CARE



FORMULATION

is a year-old who lives in in . Pt was referred for treatment by . has been a patient of Community Mental Health since .

presents with a diagnosis of that includes symptoms of


.

RISKS

Suicide Risk State: the Pts usual baseline of risk.

Suicide Risk Status: the general population, and other Pts in the current service setting.

Foreseeable changes in suicide risk:



Available resources immediately accessible to the Pt:



Other known risks to be aware of:



Diagnosis: that includes symptoms of


ISSUES IDENTIFIED AT ASSESSMENT















DISABILITY ISSUES

.

.

.

.

.

Communication Issues:


MEDICATIONS

Discharge Medication:


MH Medications Recently Ceased:


Allergies and Adverse Reactions:


RESULTS REVIEW

HoNOS:

.


Physical Investigations:


Other Results:


DISCHARGE INFORMATION

Discharge plan:


Legal Status: choose one Legal Status .

Trustee and Guardian details:


Guardianship details:


CTO details:


Involuntary Patient Order details:


Forensic Patient status details:


Other Legal Status details:


Appointments on Discharge:


Other Services Involved:


Recommended follow up:


Performed by:


Copies to:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.5, 117 form elements, 307 boilerplate words, 9 text boxes, 42 text areas, 48 checkboxes, 4 drop downs, 1 comments, 13 conditionals, 719 total clicks
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