Psychiatry
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[comment memo="Patients first name"] [text name="variable_1" default=""]

[comment memo="he or she"] [checkbox name="variable_1" value="he|she"]

[comment memo="his or her"] [checkbox name="variable_2" value="his|her"]

[comment memo="him or her"] [checkbox name="variable_3" value="him|her"]

[comment memo="Tick one box to describe the Pt concern"]

[checkbox name="variable_4" value="anxious|depressed|envious|anxious and depressed|moody|suicidal|angry|distressed|lonely|guilty|ashamed|sad|lost|abandoned|unappreciated|apathetic|ambivalent|socially disconnected|uncertain|confused|hyperactive and inattentive|agnosthesia|pâro|altschmerz|no current concerns"]

[comment memo="Agnosthesia - not sure how to feel. Pâro - everything you do is wrong. Altschmerz - weariness with the same old issues that you've always had."]

[comment memo="What situation is this feeling at its worst? Choose one"] [checkbox name="variable_50" value="at school|at home|surrounded by strangers|at work|at home in the evening|in bed late at night|just waking up in the morning|feeling trapped|lying in bed|at a social gathering|at any family gathering|in a sexual situation|anywhere in particular"]

[comment memo="With whom does this difficulty arise? Choose one"] [checkbox name="variable_51" value="a romantic partner|anyone at all|a boss|a group of work colleague|an identified bully|anyone in authority|parents|a particular teacher|a specific family member|specific family members|friends|a particular friend|the ex-partner|a specific individual"] [comment memo="first name the specific individual if necessary"][textarea name="variable_8" default=""]

[comment memo="What usually triggers the patient's concern - choose one"] [checkbox name="variable_52" value="recalls a past trauma|is in a boring or under-stimulating environment|is struggling with parenting duties|sees a frightening event in the news|has unpleasant thoughts of any kind|has unpleasant feelings of any kind|is aware of being all alone|feels that everyone is watching|feels excessive work pressure|is in the middle of intense family friction|feels threatened with a relationship breakup|is not getting replies to messages|sees hurtful messages on social media|is ruminating on past hurts|receives critical or judgemental comments|feels teased or put down|is reminded of financial pressure|feels ignored|feels invalidated|experiences physical illness symptoms|experiences unusual somatic feelings|feels harassed|is being yelled at|is having interpersonal conflict of any kind|needs to be assertive|is around unpleasant people|aware of certain unpleasant smells, tastes, or noises in the environment"]

[comment memo="Choose the patient's unhelpful thought that is triggered. Choose only one"] [checkbox name="variable_53" value="there is something wrong with me|I'm no good|I'm stupid|I'm worthless|I don't matter|I can't cope|I can't do this|I'm a failure|I'm boring|I'm better off alone|I don't need anyone|everyone leaves me|I can't be happy|I need someone to love me|everyone rejects me|If I love someone, they will leave me|the world is a dangerous place|I am not good enough|I’m different from others|I don't belong|I don't fit in|no one understands me|there is something wrong with me|I am unlovable|no one likes me|I make others feel bad|everything is my fault|I need to fix other people|I need to help others|I have to be perfect|I am selfish|I'm special|I deserve attention|everyone is stupid|I'm above the rules|I can't go wrong|I'm superior"]

[comment memo="Check one maladaptive coping behaviour"] [checkbox name="variable_54" value="restrict calories|avoid the situation|negatively ruminate|over-exercise|immerse in fantasy|actively deny the problem|become increasingly passive and helpless|renounce all self-responsibility and blame others|focus completely on external factors|shut down all emotions|daydream|act out with defiance|yell and scream|threaten suicide|self-blame|act with passive-aggression|withdraw and become quiet|blame and justify|play the victim|act in a variety of compulsive ways|frantically seek reassurance|procrastinate|over-eat|binge eat|shoplift|overspend|act promiscuously|abuse substances|abuse alcohol|self-harm"]

[comment memo="Write a brief 1-2 sentence narrative about a recent specific event that highlights the patient's current difficulty in the past tense"] [textarea name="variable_6" default="when John is at work and feels overwhelmed by having too much to do, he thinks 'what's wrong with me', feels increasingly anxious and procrastinates, making the problem worse"]

[comment memo="Tick 2 boxes only: Did they complete homework? Why?"] [checkbox name="variable_55" value="completing the homework assignment|not completing the homework assignment||because it was enjoyable|because it was helpful|because of a desire to get better|because it was easy|because it made sense to do it|because it makes life feel better|because the author said so|because of someone else's urging and coercion||because there wasn't enough spare time|because of feelings of overwhelm|because of fatigue|because it didn't make sense|because of forgetting|because it was too difficult|because it feels silly"]

[comment memo="How does the Pt rate their progress since referral"] [checkbox name="variable_56" value="feeling no change|feeling a bit worse|feeling a lot worse|feeling a bit better|feeling a lot better"]

[comment memo="Choose words to describe the patient's clothing"] [checkbox name="variable_16" value="clean|dirty|unwashed|relaxed casual|smart casual|school|formal business|relaxed business|tradie-style|quirky|eccentric|disheveled|unusual"]

[comment memo="Choose one word to describe how mood appeared"] [checkbox name="variable_17" value="euthymic|anxious|angry|apathetic|ashamed|scornful|sad|irritable|defeated|depressed|flat|hypo-manic|euphoric"]

[comment memo="Choose one word to how they described their mood"] [checkbox name="variable_18" value="fine|anxious|angry|apathetic|ashamed|scornful|sad|irritable|defeated|depressed|flat|amazing|really happy"]

[comment memo="Choose one word to describe reported mood and observed affect"] [checkbox name="variable_19" value="congruent|incongruent"]

[comment memo="Choose one word to describe the patient's attitude towards you"] [checkbox name="variable_20" value="cooperative|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|suspicious and guarded|defensive and resistant|manipulative|argumentative"]

[comment memo="Describe speech"] [checkbox name="variable_21" value="normal and clear|selectively mute|completely mute|loud|laconic|quiet and difficult to hear|pressured|rambling|babbling"]

[comment memo="Infer their thinking style from their speech"] [checkbox name="variable_22" value="logically congruent with mood and current circumstances|logically incongruent with mood and current circumstances|tending to take everything personally|assuming persecution by everyone|wrought with indecision and ambivalence|focussed on the suspicious motives of others (persecutory thinking)|deluded and unrealistic |impaired by difficulties of reference|assuming magical ideas of influence and control|distorted by hallucinations|revealing a tendency towards pseudologica fantastica"]

[comment memo="Infer their cognitive organization from their speech"] [checkbox name="variable_23" value="was otherwise unremarkable|tended to provide too much unnecessary detail (circumstantial)|wandered between too many topics (tangential thinking)|jumped from one idea to another (loose associations)|seemed to have racing thoughts (flight of ideas)|abruptly changed topic or stopped mid-sentance (thought blocking)|tended to loop or repeat themes (obsessive)|seemed stuck on over-valued ideas (preoccupations)"]

[comment memo="Any hallucinations?"] [checkbox name="variable_24" value="no hallucinations apparent or reported|auditory hallucinations reported|visual hallucinations reported"]

[comment memo="Their level of cognitive abstraction"] [checkbox name="variable_25" value="normal and flexible|too concrete and rigid|overly abstract and needlessly conceptual"]

[comment memo="How was their grasp on reality?"] [checkbox name="variable_26" value="sound|commensurate with their age and emotional development|naive but not concerning|completely distorted and concerning"]

[comment memo="How was their insight?"] [checkbox name="variable_27" value="easily makes logical connections|struggles to make logical connections|is completely unable to make logical connections|is in complete denial of the current psychological difficulties"]

[comment memo="How was their judgement?"] [checkbox name="variable_28" value="sound|fair|poor|dangerous and concerning"]

[comment memo="What was their suicide risk?"] [checkbox name="variable_29" value="no active suicidal ideation|vague suicidal ideation|intense suicidal ideation|having a suicide plan without serious intent|having strong intent to suicide without plan|having strong intent and a plan to suicide"]

[comment memo="What action did you take based on current suicide risk?"] [checkbox name="variable_30" value="I saw no need for further action today|I reminded the patient of their calling MHAL 1800011511 if needed, and urged them to present to the ED or call 000 in a crisis|Pt and I agreed to a harm minimization approach by removing access to lethal means|and I further discussed their risks with their parent"]

[comment memo="Choose one of the underlying belief systems:"]

[checkbox name="variable_40" value="ABANDONMENT beliefs - significant others providing support are unstable, unreliable or unpredictable.|MISTRUST beliefs - The expectation that others will intentionally hurt, abuse, cheat, or take advantage.|DEPRIVED beliefs - Feels emotionally deprived such that the expectation that one's desire for a normal degree of emotional support is never adequately met by others.|DEFECTIVENESS beliefs - The belief that one is inherently flawed, defective, and unlovable.|ALIENATION beliefs - The feeling that one is fundamentally different from other people, isolated, and not part of a community.|INCOMPETENCE beliefs - The belief that one is dependent of others to handle everyday life.|VULNERABILITY beliefs - The fear that an imminent and unpreventable catastrophe will strike at any time.|ENMESHMENT beliefs - Extensive emotional involvement and closeness with significant others at the expense of
full individuation.|INADEQUACY beliefs - Feels a deep sense of failing to achieve, will inevitably fail, or feels fundamentally inadequate relative to one's peers.|SUPERIORITY beliefs - The belief that one is superior and entitled to special rights and privileges.|SELF-CONTROL beliefs - Feels an inability or unwillingness to to exert self-control and tolerance of frustration to achieve one’s goals.|SUBJUGATION beliefs - The belief that one has to surrender control to others and to suppress one’s own needs and emotions.|SELF-SACRIFICE beliefs - An excessive focus on meeting the needs of others at the expense of one’s own needs and
well-being.|APPROVAL-SEEKING beliefs - Feels the need to constantly seek-approval with an excessive emphasis on gaining approval, recognition, or attention from other people, or fitting in, at the expense of developing a secure and true sense of self.|NEGATIVITY beliefs - Feels chronically pessimistic, which creates a pervasive, focus on the negative aspects of life - pain, death, loss, disappointment, conflict, guilt, resentment, unsolved problems, potential mistakes, betrayal, things that could go wrong, etc.|INHIBITION beliefs - The belief that one must inhibit spontaneous feelings and actions.|HIGH STANDARDS beliefs - The belief that one must strive to meet high internalized standards.|PUNITIVE beliefs - Feels the need to be excessively punitive which underscores the belief that people should be harshly punished for making mistakes."]

[comment memo="What is their current overall level of functioning out of 100?"] [checkbox name="variable_43" value="91 – 100 No symptoms. Superior functioning in a wide range of activities|81 – 90 Absent or minimal symptoms, good functioning in all areas|71 – 80 If symptoms are present, they are transient and expected reactions to psychosocial stressors.|61 – 70 Some mild symptoms, but generally functioning pretty well.|51 – 60 Moderate difficulty in everyday functioning.|41 – 50 Serious impairment in everyday functioning.|31 – 40 Some impairment in reality testing or communication and major impairment in several areas.|21 – 30 Behaviour is considerably influenced by poor reality testing; an inability to function in almost all areas of life.|11 – 20 Some danger of hurting self or others; occasionally fails to maintain minimal personal hygiene; gross impairment in communication.|1 – 10 Persistent danger of severely hurting self or others; persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death.|0 Inadequate information"].

[comment memo="What are the modifiable factors here?"] [checkbox name="variable_44" value="enhance mood|reduce psychotic Sx with medication|learn relaxation skills|learn mindfulness and meta-cognition skills|develop greater insight|decrease eating|increase eating|decrease ETOH|endure withdrawal of substances|enhance distress tolerance skills|boost hope|improve sleep|enhance a sense of self-efficacy|reduce pain|increase knowledge|increase assertiveness|motivate medical treatment|enhance problem-solving|increase resilience|address distorted cognitions and beliefs|treat medical concerns|improve medication adherence and compliance|enhance self-agency|strengthen ego functioning"]

[comment memo="What is the rate of progress?"] [checkbox name="variable_45 value="excellent|good|fair|poor|negligible"]

[comment memo="What factors are impacting on recovery?"] [checkbox name="variable_46" value="is highly motivated to change|lacks a strong education background|experiences significant work stress|has housing problems|has an over-burdening debt|experiences economic disadvantage|is not very psychologically minded|lack meta-cognitions|has very poor insight|lives in a difficult social environment|has financial stress|over-identifies with sick role|has ongoing legal problems|has background of childhood adversity|has history of victimization|is unemployed|has problems related to upbringing|has chronic medical problems|is pregnant|is very religious|has discord with family|has discord with most people|has extreme beliefs|has personality instability|has significant lifecycle transition difficulties|has substance misuse concerns|has low self-efficacy|has sexual difficulties|has medication adherence and compliance problems|has rigid psychological defenses|has relationship problems|has feelings of hopelessness|is unaware of problem|is denying of the problem|has secondary gains from the sick role|has no motivation to change"]

[comment memo="Tick one to describe the degree to which progress is impacted (by the above):"] [checkbox name="variable_57" value="which does not particularly impact on|which mildly impacts on|which greatly impacts on|which completely negates"]

[comment memo="Choose one of therapeutic modality"]

[checkbox name="variable_47" value="Cognitive Behavioural Therapy|Dialectical Behaviour Therapy|Behaviour Therapy|Relaxation Training|Mindfulness Training|Narrative Therapy|Group Therapy|Skills training|Psychoeducation|Insight oriented counselling|Emotional regulation skills training|Psychodynamic Counselling Techniques|enhance Psychosocial supports"]

[comment memo="add a specific technique if you want, using the format provided"] [textarea name="variable_7" default="in particular, I used guided meditation"].

[comment memo="Choose one of these diagnostic options:"]

[checkbox name="variable_48" value="Developmental Disorder|Schizophrenia Spectrum Disorder|Bipolar Disorder|Depressive Disorder|Anxiety Disorder|OCD|Trauma and Stress related Disorder|Dissociative Disorder|Somatic Symptom related|Feeding and Eating related|Elimination related|Sleep-Wake Disorder|Sexual Dysfunction|Gender Dysphoria|Impulse Control related disorder|Substance related disorder|Neurocognitive Disorder"]

[checkbox name="variable_49" value="but would not meet criteria for a diagnsosis at this time|and meets criteria for a clinical diagnosis"]

Copy the text below this line, edit it where necessary, and paste it into your EMR
-----------------------------------------------------------------------------

PATIENT'S VIEW OF PROGRESS TODAY

[text name="variable_1" default=""] reported [checkbox name="variable_55" value=""].
Overall, [checkbox name="variable_1" value=""] reports [checkbox name="variable_56" value=""] since [checkbox name="variable_2" value=""] referral.

PATIENTS DESCRIPTION OF THEIR MAIN CONCERN TODAY

[text name="variable_1" default=""] reported concerns about feeling [checkbox name="variable_4"].

[checkbox name="variable_1" value=""] provided the following example to explain [checkbox name="variable_2" value=""] presenting concerns: [textarea name="variable_6" default="when John was at work last week and felt overwhelmed by having too much to do, he thought 'what's wrong with me', felt increasingly anxious and noticed he procrastinated, making his overwhelm feel worse"]

CONTENT OF SESSION TODAY

Today [text name="variable_1" default=""] and I worked together to address [checkbox name="variable_2" value=""] feeling [checkbox name="variable_4" value=""] with [checkbox name="variable_47" value=""], [textarea name="variable_7" default=""].

CLINICAL OBSERVATIONS OF PATIENT TODAY

-- Appearance & Mood --

[text name="variable_1" default=""] presented wearing [checkbox name="variable_16" value=""] clothes. [checkbox name="variable_1" value=""] looked visibly [checkbox name="variable_17"] and reported [checkbox name="variable_2" value=""] mood as [checkbox name="variable_18" value=""] which seemed [checkbox name="variable_19" value=""]. [checkbox name="variable_2" value=""] overall attitude towards me was [checkbox name="variable_20" value=""].

-- Thinking & Judgement --

[text name="variable_1" default=""]'s speech was [checkbox name="variable_21" value=""]. Based on the content of [checkbox name="variable_2" value=""] speech I infered [checkbox name="variable_2" value=""] thinking as [checkbox name="variable_22" value=""]. I further noted [checkbox name="variable_2" value=""] thinking [checkbox name="variable_23" value=""].

There were [checkbox name="variable_24" value=""]. Overall I found [text name="variable_1" default=""]'s thinking to be [checkbox name="variable_25" value=""] and [checkbox name="variable_2" value=""] grasp on the reality of [checkbox name="variable_2" value=""] circumstances to be [checkbox name="variable_26" value=""]. On talking with [text name="variable_1" default=""] I determined [checkbox name="variable_1" value=""] [checkbox name="variable_27" value=""]. Based on recent behaviour and thinking I determined [checkbox name="variable_2" value=""] judgement to be [checkbox name="variable_28" value=""].

-- Suicide Risk --

When I asked [checkbox name="variable_3" value=""] about suicidal thinking, [checkbox name="variable_1" value=""] reported [checkbox name="variable_29" value=""]. Based on this [checkbox name="variable_30" value=""].

MY ASSESSMENT AND IMPRESSION OF THE PATIENT'S DIFFICULTIES

[text name="variable_1" default=""]'s pattern of difficulty can be expressed as follows: when [checkbox name="variable_1" value=""]'s [checkbox name="variable_50" value=""], with [checkbox name="variable_51" value=""] [textarea name="variable_8" default=""], and [checkbox name="variable_1" value=""] [checkbox name="variable_52" value=""], this makes [text name="variable_1" default=""] think '[checkbox name="variable_53" value=""]', feel increasingly [checkbox name="variable_4" value=""], and [checkbox name="variable_54" value=""] in order to cope.

On a deeper level of analysis, [text name="variable_1" default=""]'s reported struggles with feeling [checkbox name="variable_4"] likely arise due to distorted or exaggerated underlying [checkbox name="variable_40" value=""]. This would explain why [checkbox name="variable_1" value=""] thinks '[checkbox name="variable_53" value=""]', feels increasingly [checkbox name="variable_4" value=""] when triggered by emotionally stressful situations. Moreover, [checkbox name="variable_2" value=""] tendency to [checkbox name="variable_54" value=""] not only perpetuates [checkbox name="variable_2" value=""] his difficulties, but risks creating secondary problems.

Diagnostically, [text name="variable_1" default=""] has clinical features associated with [checkbox name="variable_48" value=""], [checkbox name="variable_49" value=""]

It's worth mentioning that [text name="variable_1" default=""] [checkbox name="variable_46" value=""] [checkbox name="variable_57" value=""] therapeutic progress.

Today I would rate [text name="variable_1" default=""]'s overall functioning out of 100 as: [checkbox name="variable_43" value=""]

ACTION / PLAN

I will address [text name="variable_1" default=""]'s presenting concerns with [checkbox name="variable_47" value=""].
Patients first name

he or she

his or her

him or her

Tick one box to describe the Pt concern



Agnosthesia - not sure how to feel. Pâro - everything you do is wrong. Altschmerz - weariness with the same old issues that you've always had.

What situation is this feeling at its worst? Choose one

With whom does this difficulty arise? Choose one first name the specific individual if necessary

What usually triggers the patient's concern - choose one

Choose the patient's unhelpful thought that is triggered. Choose only one

Check one maladaptive coping behaviour

Write a brief 1-2 sentence narrative about a recent specific event that highlights the patient's current difficulty in the past tense

Tick 2 boxes only: Did they complete homework? Why?

How does the Pt rate their progress since referral

Choose words to describe the patient's clothing

Choose one word to describe how mood appeared

Choose one word to how they described their mood

Choose one word to describe reported mood and observed affect

Choose one word to describe the patient's attitude towards you

Describe speech

Infer their thinking style from their speech

Infer their cognitive organization from their speech

Any hallucinations?

Their level of cognitive abstraction

How was their grasp on reality?

How was their insight?

How was their judgement?

What was their suicide risk?

What action did you take based on current suicide risk?

Choose one of the underlying belief systems:



What is their current overall level of functioning out of 100? .

What are the modifiable factors here?

What is the rate of progress?

What factors are impacting on recovery?

Tick one to describe the degree to which progress is impacted (by the above):

Choose one of therapeutic modality



add a specific technique if you want, using the format provided.

Choose one of these diagnostic options:





Copy the text below this line, edit it where necessary, and paste it into your EMR
-----------------------------------------------------------------------------

PATIENT'S VIEW OF PROGRESS TODAY

reported .
Overall, reports since referral.

PATIENTS DESCRIPTION OF THEIR MAIN CONCERN TODAY

reported concerns about feeling .

provided the following example to explain presenting concerns:

CONTENT OF SESSION TODAY

Today and I worked together to address feeling with ,.

CLINICAL OBSERVATIONS OF PATIENT TODAY

-- Appearance & Mood --

presented wearing clothes. looked visibly and reported mood as which seemed . overall attitude towards me was .

-- Thinking & Judgement --

's speech was . Based on the content of speech I infered thinking as . I further noted thinking .

There were . Overall I found 's thinking to be and grasp on the reality of circumstances to be . On talking with I determined . Based on recent behaviour and thinking I determined judgement to be .

-- Suicide Risk --

When I asked about suicidal thinking, reported . Based on this .

MY ASSESSMENT AND IMPRESSION OF THE PATIENT'S DIFFICULTIES

's pattern of difficulty can be expressed as follows: when 's , with , and , this makes think ' ', feel increasingly , and in order to cope.

On a deeper level of analysis, 's reported struggles with feeling likely arise due to distorted or exaggerated underlying . This would explain why thinks ' ', feels increasingly when triggered by emotionally stressful situations. Moreover, tendency to not only perpetuates his difficulties, but risks creating secondary problems.

Diagnostically, has clinical features associated with ,

It's worth mentioning that therapeutic progress.

Today I would rate 's overall functioning out of 100 as:

ACTION / PLAN

I will address 's presenting concerns with .

Result - Copy and paste this output:

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