Psychiatry & Psychology
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[checkbox value="Face-to-face apt. in clinical consulting room|Clinical interview with Pt via telephone|Clinical interview with Pt via video link|Clinical interview with Pt at their home|Clinical interview with Pt in the Community"] for the purpose of [checkbox value="mental state evaluation|psychotherapy|DEPOT|psychotherapy|welfare check|psychiatry apt"]

SUBJECTIVE

Pt reported feeling [text default=""], about [text default=""], stating: [textarea default=""].

OBSERVATIONS

Overall grooming was [select value="unremarkable|neglected|immaculate"].
Pt looked [checkbox value="average weight|overweight|underweight"][checkbox value="+|++|+++"]
Behaviour was [select value="well-regulated|over-regulated|poorly-regulated"][checkbox value="+|++|+++"]
Posture was [checkbox value="relaxed|rigid|stooped|confident|aggressive|tense|slumped"][checkbox value="+|++|+++"]
Movement was [checkbox value="unremarkable|odd / peculiar|slowed|repetitive|restless|agitated|tremorous"][checkbox value="+|++|+++"]

[checkbox value="maintained focus and attention|seemed unaware|inattentive|distractible|hyper-vigilant|scattered concentration|preoccupied|confused|focused on irrelevancies"][checkbox value="+|++|+++"]

[checkbox value="engaged well with me|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|manipulative|argumentative"][checkbox value="+|++|+++"]

Mood & Affect: [checkbox value="emotionally expressive|tearful|labile affect|restricted affect|blunted affect|flat affect|dysphoric|anxious|angry |apathetic|ashamed|prideful|sad|irritable|hostile|pessimistic|depressed|manic|euphoric|neutral"][checkbox value="+|++|+++"]

Speech was [checkbox value="clear and articulate|selectively mute|completely mute|loud|laconic|ranting|verbose|quiet|pressured|rambling|babbling|incongruent with mood and current circumstances"][checkbox value="+|++|+++"]

Thinking: [checkbox value="logical and reality-based|rigid and concrete|tended to personalize|persecutory|indecisive and ambivalent|deluded and unrealistic|impaired by difficulties of reference|assumed magical ideas of influence and control|distorted|prone to 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)"][checkbox value="+|++|+++"]

Orientation: [checkbox value="no concerns|AH reported|VH reported|poor judgement|poor reality testing|poor insight|complete denial"][checkbox value="+|++|+++"]

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"].

ASSESSMENT

[checkbox value="Pt is|Pt and family are|Pt and school are"]
likely feeling [text default=""], about [text default=""] due to [checkbox name="variable_40" value="nothing particularly stressful happening at the moment|ABANDONMENT beliefs - that significant others providing support are unstable, unreliable or unpredictable.|MISTRUST beliefs - That others will intentionally hurt, abuse, cheat, or take advantage.|DEPRIVED beliefs - the need for emotional support is never adequately met by others.|DEFECTIVENESS beliefs - That one is inherently flawed, defective, and unlovable.|ALIENATION beliefs - That one is fundamentally different from other people, isolated, and not part of a community.|INCOMPETENCE beliefs - That one is dependent of others to handle everyday life.|VULNERABILITY beliefs - That an imminent and unpreventable catastrophe will strike at any time.|ENMESHMENT beliefs - Extensive emotional involvement and closeness with significant others is preferable at the expense of
individuation.|INADEQUACY beliefs - That one will inevitably fail, or feels fundamentally inadequate relative to one's peers.|SUPERIORITY beliefs - 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 - 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 - That one must inhibit spontaneous feelings and actions.|HIGH STANDARDS beliefs - 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?"]
Global functioning: [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"].

Factors inmpacting on recovery: [checkbox value="nothing of note|is not very 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"].

ACTION

[comment memo="What action did you take based on current suicide risk?"]
Risk: [checkbox value="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"]

Worked with Pt to [checkbox name="variable_44" value="tolerate distress|learn relaxation skills|learn mindfulness and meta-cognitive skills|develop greater insight|decrease over-eating behaviours|increase eating and calories|decrease ETOH misuse|endure withdrawal of substances|feel more hopeful about the future|improve sleep|enhance a sense of self-efficacy|increase psychological knowledge|become more assertive|adhere to recommended medical treatment|enhance problem-solving skills|modify distorted cognitions and beliefs|become motivated to treat MH concerns|improve medication adherence and compliance|feel enhanced self-agency"]

Progress: [checkbox name="variable_45 value="excellent|good|fair|poor|negligible"]

PLAN

[textarea default="Next apt. "]
for the purpose of

SUBJECTIVE

Pt reported feeling , about , stating:.

OBSERVATIONS

Overall grooming was .
Pt looked
Behaviour was
Posture was
Movement was





Mood & Affect:

Speech was

Thinking:

Orientation:

Suicide risk: .

ASSESSMENT


likely feeling , about due to

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

Factors inmpacting on recovery: .

ACTION

What action did you take based on current suicide risk?
Risk:

Worked with Pt to

Progress:

PLAN

Result - Copy and paste this output:
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