MH Review 7

COMMUNITY MENTAL HEALTH PATIENT REVIEW

REVIEW / MANAGEMENT 

SUMMARY OF TREATMENT

[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=""]

OTHER ISSUES IDENTIFIED AT ASSESSMENT 

[checkbox name="Q1" value="education and literacy:"][conditional field="Q1" condition="(Q1).is('education and literacy:')"] [checkbox name="education" value="Z55.0 Illiteracy and low-level literacy|Z55.1 Schooling unavailable and unattainable|Z55.2 Failed examinations|Z55.3 Underachievement in school|Z55.4 Educational maladjustment and discord with teachers and classmates|Z55.8 Other problems related to education and literacy|Z55.9 Problem related to education and literacy, unspecified"][/conditional]

[checkbox name="Q2" value="employment:"][conditional field="Q2" condition="(Q2).is('employment:')"] [checkbox name="employment" value="Z56.0 Unemployment, unspecified|Z56.1 Change of job|Z56.2 Threat of job loss|Z56.3 Stressful work schedule|Z56.4 Discord with boss and workmates|Z56.5 Difficult conditions at work|Z56.6 Other physical and mental strain related to work|Z56.7 Other and unspecified problems related to employment"][/conditional]

[checkbox name="Q5" value="housing and economic circumstances:"][conditional field="Q5" condition="(Q5).is('housing and economic circumstances:')"] [checkbox value="Z59.0 Homelessness|Z59.1 Inadequate housing|Z59.2 Discord with neighbours, lodgers and landlord|Z59.3 Problems related to living in residential institution|Z59.4 Lack of adequate food|Z59.5 Extreme poverty|Z59.6 Low income|Z59.7 Insufficient social insurance and welfare support|Z59.8 Other problems related to housing and economic circumstances|Z59.9 Problem related to housing and economic circumstances, unspecified"][/conditional]

[checkbox name="Q7" value="social environment:"][conditional field="Q7" condition="(Q7).is('social environment:')"] [checkbox value="Problems of adjustment to life-cycle transitions|Z60.1 Atypical parenting situation|Z60.2 Living alone|Z60.3 Acculturation difficulty|Z60.4 Social exclusion and rejection|Z60.5 Target of perceived adverse discrimination and persecution|Z60.8 Other problems related to social environment|Z60.9 Problem related to social environment, unspecified"][/conditional]

[checkbox name="Q9" value="negative life events in childhood:"][conditional field="Q9" condition="(Q9).is('negative life events in childhood:')"] [checkbox value="Z61.0 Loss of love relationship in childhood|Z61.1 Removal from home in childhood|Z61.2 Altered pattern of family relationships in childhood|Z61.3 Events resulting in loss of self-esteem in childhood|Z61.4 Problems related to alleged sexual abuse of child by person within primary support group|Z61.5 Problems related to alleged sexual abuse of child by person outside primary support group|Z61.6 Problems related to alleged physical abuse of child|Z61.7 Personal frightening experience in childhood|Z61.8 Other negative life events in childhood|Z61.9 Negative life event in childhood, unspecified|Z62 Other problems related to upbringing (not maltreatment)"][/conditional]

[checkbox name="Q10" value="upbringing:"][conditional field="Q10" condition="(Q10).is('upbringing:')"] [checkbox value="Z62.0 Inadequate parental supervision and control|Z62.1 Parental overprotection|Z62.2 Institutional upbringing|Z62.3 Hostility towards and scapegoating of child|Z62.4 Emotional neglect of child|Z62.5 Other problems related to neglect in upbringing|Z62.6 Inappropriate parental pressure and other abnormal qualities of upbringing|Z62.8 Other specified problems related to upbringing|Z62.9 Problem related to upbringing, unspecified"][/conditional]

[checkbox name="Q11" value="primary support group:"][conditional field="Q11" condition="(Q11).is('primary support group:')"] [checkbox value="Z63.0 Problems in relationship with spouse or partner|Z63.1 Problems in relationship with parents and in-laws|Z63.2 Inadequate family support|Z63.3 Absence of family member|Z63.4 Disappearance and death of family member|Z63.6 Dependent relative needing care at home|Z63.7 Other stressful life events affecting family and household|Z63.8 Other specified problems related to primary support group|Z63.9 Problem related to primary support group, unspecified"][/conditional]

[checkbox name="Q12" value="psychosocial circumstances:"][conditional field="Q12" condition="(Q12).is('psychosocial circumstances:')"] [checkbox value="Z64.0 Problems related to unwanted pregnancy|Z64.1 Problems related to multiparity|Z64.2 Seeking and accepting physical, nutritional and chemical interventions known to be hazardous and harmful|Z64.3 Seeking and accepting behavioural and psychological interventions known to be hazardous and harmful|Z64.4 Discord with counsellors"][/conditional]

[checkbox name="Q13" value="other psychosocial circumstances:"][conditional field="Q13" condition="(Q13).is('other psychosocial circumstances:')"] [checkbox value="Z65 Problems related to other psychosocial circumstances (legal and military)|Z65.0 Conviction in civil and criminal proceedings without imprisonment|Z65.1 Imprisonment and other incarceration|Z65.2 Problems related to release from prison|Z65.3 Problems related to other legal circumstances|Z65.4 Victim of crime and terrorism|Z65.5 Exposure to disaster, war and other hostilities|Z65.8 Other specified problems related to psychosocial circumstances|Z65.9 Problem related to unspecified psychosocial circumstances"][/conditional]

[textarea default=""]

-- Disability Issues --

[checkbox value="Nothing of note|Cognition – understanding and communicating|Mobility – moving and getting around|Self-care – attending to one’s hygiene, dressing, eating and staying alone|Getting along – interacting with other people|Life activities – domestic responsibilities, leisure, work and school|Participation – joining in community activities, participating in society."]

PROGRESS

At our last contact I would rate the severity of [text default="the patient's"] illness as [select value="stable and without symptoms|fully recovered|mildly ill|moderately ill|severely ill|among the most extremely ill patients"]. 
Compared to the patients condition on admission, I rate progress as: [select value="much improved|minimally improved|no change|minimally worse|much worse|unable to be assessed"]. 
The patient reports recovery as: [select value="feeling much improved|feeling minimally improved|feeling no change|feeling minimally worse|feeling much worse"]. 

[textarea default=""]

REASON FOR REVIEW

[select value="13-week review|risk re-assessment|change in clinical status"]

REASON FOR REFERRAL

Pt was referred to Community Mental Health 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"].

MEDICATIONS:

[textarea default=""]

ASSESSMENT OF RISKS:

[textarea default="No historical risks identified. No current risks identified. No foreseeable risks identified. See full risk assessment DATE."]

IMPRESSION AND PLAN

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]

[checkbox name="impac" value="Progress towards discharge has been impacted by these recovery barriers:"][conditional field="impac" condition="(impac).is('Progress towards discharge has been impacted by these recovery barriers:')"] [checkbox value="precontemplative stage of motivation|denies the mental health diagnosis|symptom severity|denies illness|lack of family cohesion|lives remotely|transient lifestyle|symptom frequency|personality factors|unable to link with a GP|over-reliance on Community Mental Health|coping skills deficits|poor rapport| unrealistic expectations for recovery|unrealistic expectations for mental health services|poor adjustment to mental health symptoms|unpleasant side effects from medication|poor compliance with medication|unreliable with scheduled appointments|routinely fails to respond to service contact requests|avoids service contact|is not hopefully about the future|does not desire change|is unwilling to play an active role in recovery|identifies with the sick role|has poor executive control|does not derive much benefit from treatment|social isolation|lacks family support|continues to abuse substances|feels stigmatized by the mental health diagnosis|engages in splitting behaviours|is negative towards this mental health service|shy and inhibited temperament|overwhelmed by symptoms associated with mental health diagnosis|poor cohesion between services supporting patient|complicated by medical problems|a history of childhood adversity|complicated by multiple co-occurring mental health concerns|executive function difficulties|intellectual difficulties|tends to exaggerate concerns|receives secondary gains from current mental health status and functioning|has poor rapport with the author"] [textarea cols=80 rows=5 default=""][/conditional]

PLAN

[checkbox value="continue with psychiatric medication|medication review|psychiatric review and assessment|case management|community treatment order|clozapine management|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|group therapy|safeside counselling referral|Pt advocacy|laising with trustee and guardian|treatment planning|safety planning|discharge from service"] [textarea default=""]

CLINCIANS IN REVIEW

[textarea default=""]