MH – ISBAR for Adolescent Mental Health

[comment memo="INTRODUCTION"]
The Pt, [text default="NAME"], is a [text default=""] year old [select value="female|male"] born [text default="DOB"]. [checkbox value="His|Her"] legal guardian is [text default=""] [text default="and XXX"]. 

Pt [text default="identified/is not identified"] as ATSI, and CALD status is [text default="denied"].

[comment memo="SITUATION"]
[text default="Name"] presented to our service reporting symptoms of [checkbox value="depressed mood|anhedonia|irritability|hopelessness|guilt|low self-esteem|fatigue|changes in appetite|sleep disturbances|psychomotor agitation|psychomotor retardation|difficulty concentrating|indecisiveness|suicidal ideation|hallucinations|delusions|paranoia|disorganized thoughts|manic episodes|hypomanic episodes|panic attacks|anxiety|excessive worry|social withdrawal|isolation|apathy|obsessions|compulsions|intrusive thoughts|flashbacks|nightmares|difficulty trusting others|difficulty regulating emotions|impulsivity|recklessness|substance use|eating disturbances|body image concerns|self-harm|aggressive behaviours|dissociation|memory problems|excessive guilt|intrusive memories|irrational fears|excessive cleaning|perfectionism|thoughts of hurting others|difficulty managing anger|substance withdrawal symptoms"] and 
complaining of decline in functioning around [checkbox value="school attendance|academic performance|relationships with peers|family relationships|self-esteem|physical health|sleep patterns|attending to ADLS|social activities|emotional well-being|concentration and focus|decision-making|motivation|appetite and eating habits|hobbies and interests|communication skills|goal setting and future plans|overall ability to cope"]. 

[comment memo="BACKGROUND"]
These mental health concerns arose about [textarea default="XX TIME ago"] in the context of [textarea default=""]. Since that time, [checkbox name="past_treatments" value="the Pt has not tried any mental health treatments.|mental health treatments have included"][conditional field="past_treatments" condition="(past_treatments).is('mental health treatments have included')"][checkbox value="counseling|medication therapy|inpatient hospitalization|outpatient programs|lifestyle changes|drug and alcohol counselling|family therapy|school counselling|group therapy|individual therapy|psychiatric evaluation|alternative therapies|self-help strategies"][textarea cols=60 rows=5 default="Details"].
Treatment effectiveness has been [checkbox value="excellent|good|fair|poor|uncertain"][/conditional].

[checkbox name="psychosocial_stressors" value="No psychosocial stressors of note identified.|Psychosocial stressors impacting on family include"]
[conditional field="psychosocial_stressors" condition="(psychosocial_stressors).is('Psychosocial stressors impacting on family include')"] [checkbox value="family conflict|DV|relationship problems|work stress|financial stress|health-related concerns|grief and loss|divorce or separation|traumatic events|substance abuse|isolation or loneliness|cultural issues|legal problems|housing instability|parenting challenges|relationship or marital problems"] [textarea cols=60 rows=5 default="details"] [/conditional]

[checkbox name="family_mental_health" value="No history of family mental health reported.|Family mental health history includes"] [conditional field="family_mental_health" condition="(family_mental_health).is('Family mental health history includes')"] [checkbox value="mood disorders|anxiety disorders|psychotic disorders|obsessive-compulsive and related disorders|trauma and stressor-related disorders|substance-related and addictive disorders|eating disorders|neurodevelopmental disorders|personality disorders"][textarea cols=60 rows=5 default="Details"][/conditional]

[checkbox name="medical_illness" value="There are no medical conditions of note|Pt has identified medical barriers to recovery that include"]
[conditional field="medical_illness" condition="(medical_illness).is('Pt has identified medical barriers to recovery that include')"][checkbox value="cardiovascular concerns|respiratory problems|gastrointestinal issues|endocrine disorders|neurological conditions|musculoskeletal problems|renal disorders|dermatological conditions|hematological issues|immunological disorders|infectious diseases|psychiatric conditions"][textarea cols=60 rows=5 default="Details"][/conditional]. 

[checkbox name="family_medical_history" value="No family medical concerns were identified|There is a family medical history of"] [conditional field="family_medical_history" condition="(family_medical_history).is('There is a family medical history of')"][checkbox value="cardiovascular conditions|respiratory problems|gastrointestinal issues|endocrine disorders|neurological conditions|musculoskeletal problems|renal disorders|dermatological conditions|hematological issues|immunological disorders|infectious diseases|psychiatric conditions"] [textarea cols=60 rows=5 default="Details"][/conditional]

[checkbox name="self_harm_risk_history" value="There is no reported history of self-harm risk.|The Pt has a self-harm risk history that includes"]
[conditional field="self_harm_risk_history" condition="(self_harm_risk_history).is('The Pt has a self-harm risk history that includes')"]: [checkbox value="previous self-harm incidents without suicidal intent|using objects to self-harm (e.g., blades, heated metal)|self-inflicted burns|scratching or biting oneself|family history of self-harm|psychiatric hospitalization for self-harm thoughts/behaviours"] [textarea cols=60 rows=5 default="Details"][/conditional]

[checkbox name="suicide_risk_history" value="There is no reported history of suicide risk.|The Pt has a suicide risk history that includes"]
[conditional field="suicide_risk_history" condition="(suicide_risk_history).is('The Pt has a suicide risk history that includes')"]: [checkbox value="previous suicide attempts|self-harm behaviours|suicidal ideation only|family history of suicide|psychiatric hospitalization for suicidal thoughts/behaviours"][/conditional]

[checkbox name="aggression_risk_history" value="There is no reported history of aggression.|The Pt has a past history of aggression that includes"]
[conditional field="aggression_risk_history" condition="(aggression_risk_history).is('The Pt has a past history of aggression that includes')"] [checkbox value="verbal outbursts|physical aggression|property damage|threats and intimidation"][/conditional]

[textarea default="No current legal issues"].
Current people involved in the Pts care include [textarea default="Parents, NGO, NDIS, FACS, GP, Medical Specialists, Justice"]

[comment memo="ASSESSMENT"]
My impression is that [text default="NAME"] presents with diagnostic features of [checkbox value="a mood disorder|an anxiety disorder|a neurodevelopmental disorder|an eating disorder|a substance-related disorder|a psychotic disorder|a personality disorder|a trauma and stress related disorder|a disruptive, impulse-control, and conduct disorder"]. Which is [checkbox value="severely|moderately|occassionally, but persistently|minimally"] impacting on [checkbox value="school attendance|academic performance|relationships with peers|family relationships|self-esteem|physical health|sleep patterns|attending to ADLS|social activities|emotional well-being|concentration and focus|decision-making|motivation|appetite and eating habits|hobbies and interests|communication skills|goal setting and future plans|coping strategies"]. 

[checkbox name="maladaptive_defenses" value="No maladaptive defenses identified.|Maladaptive defenses include"] [conditional field="maladaptive_defenses" condition="(maladaptive_defenses).is('Maladaptive defenses include')"] [checkbox value="denying and accepting reality|projecting unwanted feelings onto others|acting out emotions rather than addressing them directly|dissociating from certain events or feelings to avoid emotional distress|regressing to a younger stage of development in response to stress|escaping an unpleasant reality by fantasizing|rationalizing excuses for maladaptive behaviours and feelings|expressing anger or resentment in indirect ways|displacing true feelings into safer outlets|avoiding emotional issues by intellectualsing"][textarea cols=60 rows=5 default="details"][/conditional]

[checkbox name="mature_defenses" value="No mature defenses identified.|Mature defenses include"] [conditional field="mature_defenses" condition="(mature_defenses).is('Mature defenses include')"] [checkbox value="sublimating negative emotions into socially acceptable actions|altruistically giving to others without expecting anything in return|suppressing attention to certain negative emotions to get through the day|using humour to express discomfort|anticipating and positively preparing for future events to avoid overwhelm|turning to others for support during emotional distress|self-observing actions and emotions without judgment|expressing feelings and thoughts assertively and constructively"][textarea cols=60 rows=5 default="details"][/conditional]

[checkbox name="recovery_barriers" value="Fortunately there are no identified barriers to recovery.|There are barriers to recovery that include"] [conditional field="recovery_barriers" condition="(recovery_barriers).is('There are barriers to recovery that include')"]
[checkbox value="lack of access to treatment|stigma|poor insight|external locus of control|secondary gains|lack of family support|financial burden|co-occurring disorders|environmental factors|social isolation|educational challenges|cultural barriers|trauma history|substance abuse|physical health issues|lack of motivation"][/conditional]. [checkbox name="factors_promoting_recovery" value="Unfortunately there are no identified factors promoting recovery.|However, there are factors promoting recovery that include"][conditional field="factors_promoting_recovery" condition="(factors_promoting_recovery).is('However, there are factors promoting recovery that include')"] [checkbox value="supportive social network|access to treatment|motivation|self-efficacy|positive coping skills|stable living environment|healthy lifestyle choices|regular exercise|good nutrition|meditation and mindfulness|medication adherence|therapeutic relationships|psychoeducation|sense of humour|positive role models"]
[/conditional]. 

[comment memo="RECOMMENDATION"]
At the time of writing, the prognosis is [checkbox value="excellent|good|fair|guarded|poor"]. I am refering this Pt to [text default="SERVICE"] as more support is needed with [checkbox value="depression|anxiety|social isolation|suicide risk|self-harm|aggression|peer relationships|bullying|academic stress|self-esteem issues|substance abuse|body image concerns|self-harm tendencies|eating disorder|suicidal thoughts|attention-deficits|obsessive-compulsive disorder|mood swings|PTSD|gender identity concerns|sexual orientation concerns|family conflicts|grief and loss|anger management|sleep disturbances|medication management"][textarea default=""]
INTRODUCTION
The Pt, , is a year old born . legal guardian is .

Pt as ATSI, and CALD status is .

SITUATION
presented to our service reporting symptoms of and
complaining of decline in functioning around .

BACKGROUND
These mental health concerns arose about
in the context of
. Since that time, .







.












.
Current people involved in the Pts care include


ASSESSMENT
My impression is that presents with diagnostic features of . Which is impacting on .





. .

RECOMMENDATION
At the time of writing, the prognosis is . I am refering this Pt to as more support is needed with

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.6, 74 form elements, 85 boilerplate words, 10 text boxes, 13 text areas, 33 checkboxes, 1 drop downs, 5 comments, 12 conditionals, 311 total clicks
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