MH – Comprehensive SOAPNOTE with risk Ax
SITUATION [text default="Name"] is a [text default="X year old"] [select value="female|male"] [select value="voluntary|involuntary"] Pt, presenting with: [checkbox value="acute mental health distress|multiple complex psychosocial issues|a developmental disorder|schizophrenia spectrum disorder|a situational crisis|thoughts of suicide|thoughts of harm to others|thoughts of self-harm|bipolar disorder|depressive disorder|anxiety disorder|OCD|a trauma and stress related disorder|a dissociative disorder|a somatic symptom disorder|a feeding and eating related disorder|an elimination related disorder|a sleep-wake disorder|sexual dysfunction|gender dysphoria|impulse control related disorder|substance related disorder|a neurocognitive disorder|a personality disorder"] [textarea default=""], which can be characterised by these symptoms: [checkbox value="fear and worry|panic|behavioural avoidance|clinging and neediness|pacing|anxiety|irritability|low mood|sadness|inner emptiness|anhedonia|poor concentration|disturbed sleep cycle|guilt|low self-worth|hopelessness|thoughts of suicide|disturbed sleep|dissociation|provocative behaviours|compulsions|domineering others|eccentricities|emotional detachment|negativism|denial|projection|splitting|passivity|loss of appetite|increase in appetite|lethargy|euphoria|excessive energy|talkativeness|racing thoughts|grandiosity|impulsivity|insomnia|decreased need for sleep|flashbacks|nightmares|intrusive thoughts|heightened threat sensitivity|perceptual disturbance|disorganised thinking|disorganised behaviours|agitation|cognitive difficulties|speech difficulties|hallucinations|delusions|vulnerabilty to exploitation|social withdrawal|amotivation|impaired reality-testing|unhealthy weight loss|unhealthy weight gain|medical problems associated with low BMI|body dysmorphia|alexithymia|medical problems associated with high BMI|family discord|purging|unhealthy weight loss techniques|preoccupation with food|over-valued body ideals|inattention|distractibility|hyperactivity|intellectual difficulties|social difficulties|obsessions|unhealthy preoccupations|cognitive inflexibility|poor social reciprocity|language difficulties|insightlessness|treatment refusal|poor medication adherence|legal difficulties|debts|reputational damage|housing difficulties|unemployment|poverty|unhealthy lifestyle choices|financial stress|oppositional behaviours|substance misuse"]. Today's contact was [select value="planned|unplanned"] in [select value="CMH|the Emergency Department|a medical ward|the MH-IPU|Pts home|a phone call|the community|private practice"] for the purpose of [checkbox value="case management and care planning|treatment planning|mental health triage|psychiatric evaluation|DEPOT medication|acute MH reponse|PRN medication|medication scripts|mental state evaluation and assessment|psychosocial support and planning|CTO planning|psychotherapy|peer support|risk assessment and planning|care planning"] [textarea default=""]. OBSERVATIONS The Pt is a [text default="X year old"] [select value="female|male"], who appears to be [select value="of|older than|younger than"] stated age, is [select value="an average build|of slim build|of small build|of muscular build|of tall build"] and looks [select value="average weight|overweight|underweight|obsese|extremely underweight"] relative to build. Grooming, hygiene and self-care is [select value="appropriate|neglected|immaculate"] [select value="+|++|+++"]. The Pts clothing is [checkbox value="neat, clean, casual and appropriate|clean|inappropriate for age|inappropriate for occassion|meticulous|disheveled|dirty|bizarre|malodourous"] and the posture is [select value="relaxed|rigid|restricted|constricted|stooped|confident|aggressive|tense|slumped|knees pulled to chest"] [select value="+|++|+++"]. In terms of engagement, [text default="NAME"] presents as [select value="generally positive and cooperative|obliging, but taciturn|overfamiliar and poorly respectful of boundaries|guarded and difficult to access|hostile and threatening|anxious and difficult to contain|needy and acopic|resentful and complaining|dramatic and exaggerating concerns|ambivalent and hard to read|disinterested|silly and joking around|passively resistant and aloof|hostile and threatening|sarcastic and taunting|fatuous and evasive|flirtatious and sexually inappropriate|demanding and impossible to please|paranoid and assuming harm|inaccessible and difficult to assess|grossly affected by the MH symptoms to the point where engagement is impossible"] [select value="+|++|+++"], and the [select value="facial|vocal"] expression is [select value="smiling|relaxed|neutral|unreadable|anxious|worried|sad|flat|angry|suspicious|haughty|scowling|sleepy"]. During this encounter the Pts attention is [select value="appropriately focussed on the author|focussed on irrelevancies|distractible|vigilant|preoccupied"] [select value="+|++|+++"] and the Pt is [checkbox value="oriented to person, place and time|generally oriented but|affected by AH|affected by VH|affected by AH and VH|influenced by delusions and unrealistic preoccupations|substance affected|disoriented to person|disoriented to place|disoriented to time"]. The psychomotor activity is [select value="relaxed and otherwise unremarkable|slowed|restless|agitated|odd|notable in terms of involuntary movements"]. The reported mood is [text default=""]. The observed quality of the emotional state is [select value="euthymic|sad|angry|hostile|pleading|indifferent|flat|dysphoric|detached|elated|euphoric|anxious|animated|irritable"] [select value="+|++|+++"] and [checkbox value="congruent with reported mood|incongruent with reported mood"]. The quality of speech is [checkbox value="clear and articulate|selectively mute|completely mute|flat|loud|concise|lacking detail|verbose|mumbling|whispering|quiet|pressured|ranting|rambling|babbling|aphasic|incongruent with mood and current circumstances"] [select value="+|++|+++"]. The thinking style is [checkbox value="logical and flexible|rigid and concrete|logical and otherwise unremarkable|personalizing|persecutory|indecisive|unrealistic|impaired by difficulties of reference|assuming magical ideas of influence and control|grossly distorted|confabulatory|affected by memory recall problems|provides unnecessary details|wandering between many topics|jumping from one idea to another|racing and filled with appealing but unrealistic ideas|blocking on occassion|looping and repeating themes|stuck on over-valued ideas"] [select value="+|++|+++"]. Issues of concern the Pt raised without prompting: [checkbox value="nothing in particular|medications|a psychiatry review|date of next apt|side effects of meds|scripts|self-esteem|suicidal ideation|self-harm|parenting|money|troubling thoughts|school|physical health|energy|sleep|housing|unemployment|diet|bodyweight|obsessions|mood problems|emotional regulation problems|family problems|work stress|grief and loss|illness|lack of role|body image|neighbours|support workers|bad memories|CTO|drug use|legal problems|children|parents|complaints about the service and quality of care|transitions|peers|grief|relationship problems"] [textarea default=""] which seemed [checkbox value="appropriate|acceptable|realistic|inappropriate|exagerated|naive|unrealistic"] to the author . The Pts cognitive functioning is [checkbox value="intact and otherwise unremarkable|impacted by symptoms of mental illness|affected by poor memory|impacted by attention difficulties|impaired in understanding and comprehension|affected by a reduced level of consciousness and general alertness|affected by substance use|medication affected"] [textarea default=""]. Based on the Pts understanding on the reason for our contact today, insight seems [select value="intact|partial|poor"] and judgement is [select value="intact|partial|poor"]. When asked about self-harm, suicide, and harm to others, the Pt [select value="denied it|disclosed episodic TOSH without SI|disclosed TOHTO without intent|disclosed TOHTO with intent to act|disclosed TOHTO and confirmed previous acts|disclosed episodic TOSH with SI but no plans or serious intent|disclosed NSSI|disclosed vague SI with no serious intent|disclosed intense SI with no serious intent|disclosed SI, a suicide plan but without strong intent|disclosed strong intent to suicide without a specific plan|disclosed strong intent and a plan to complete suicide|expressed an immediate suicidal crisis and feels unsafe to be left alone"]. ASSESSMENT Impression: the Pts symptoms associated with [checkbox value="acute mental health distress|complex mental health and psychosocial issues|a developmental disorder|schizophrenia spectrum disorder|a situational crisis|acute but nonspecific mental health concerns|suicide risk|violence risk|reptuation risk|financial risk|NSSI|bipolar disorder|depressive disorder|anxiety disorder|OCD|a trauma and stress related disorder|a dissociative disorder|a somatic symptom disorder|a feeding and eating related disorder|elimination related disorder|sleep-wake disorder|sexual dysfunction|gender dysphoria|impulse control related disorder|substance related disorder|a neurocognitive disorder|a personality disorder"] [textarea default=""], appear to be [select value="in remission|mild intensity|moderate intensity|severe intensity"], which have a [select value="negligible|minimal but occassionally marked|persistent and at times significant|persistent, considerable and frequently overwhelming"] impact on the Pts life overall. From our contact today, the Pts symptoms appear to be [select value="stable|improved|worsening"] since [select value="the inital referral|last clinical contact"], the overall clinical progress is [select value="static|slow|fair|good"], and global assessment of functioning is: [select value="100-99 Superior functioning in a wide range of activities. No symptoms.|90-81 Absent or minimal symptoms. Good functioning in all areas, interested and involved in a wide range of activities. Socially effective, generally satisfied with life, no more than everyday problems or concerns|80-71 If symptoms are present, they are transient and expectable reactions to psychosocial stressors.|70-61 Some mild symptoms OR some difficulty in social , occupational, but generally functioning pretty well, has some meaningful interpersonal relationships.|60-51 Moderate symptoms OR moderate difficulty in social, or occupational functioning.|50-41 Serious symptoms OR any serious impairment in social, or occupational.|40-31 Some impairment in reality testing or communication OR major impairment in several areas of life|30-21 Behaviour is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment OR inability to function in almost all areas|20-11 Some danger of hurting self or others OR occasionally fails to maintain minimal personal hygiene OR gross impairment in communication.|10-1 Persistent danger of severely hurting self or others OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.|0 Inadequate information.|unable to rate"]. Based on todays contact, ongoing areas of concern are: [checkbox value="nothing of note|self-care and apearance|behavioural issues|self-esteem and self-concept|rapport and attitude|mood and affect|perceptual disturbance|Pts thinking style|content of the thoughts and ideas the Pt expressed|orientation to reality|cognitive functioning|insight and judgement|suicide|self-harm|harm to others|overall welfare"] [textarea default=""]. Enduring factors impacting on the Pts overall mental health recovery: [checkbox value="nothing of note|symptom severity|poor response to medication|lack of social support|passive temperament|hostile temperament|fixed delusions|difficult psychosocial circumstances|disadvantaged cultural circumstances|over-valued ideas|has an undesirable social reputation|tends to burn bridges|ongoing legal problems|crushing debts|itinerancy|lack of emotional coping skills|lacks a strong education background|impulsivity problems|cultural dislocation|victim of violence|not psychologically minded|limited self-reflection|poor insight|lives in a difficult social environment|a background of childhood adversity|history of victimization|limited unemployment skills|poverty|medical problems|physical disability|social isolation|external locus of control|problems related to upbringing|chronic medical problems|extreme personal beliefs|personality instability|lifecycle transition difficulties|intellectual and cognitive difficulties"] [textarea default=""]. [comment memo="Tick and complete -- Suicide Risk Assessment -- if you have current suicide risk concerns"] [checkbox name="suic" value="-- Suicide Risk Assessment --"][conditional field="suic" condition="(suic).is('-- Suicide Risk Assessment --')"] The Pts suicide risk status is: [checkbox value="higher than|the same as"] the general population. Enduring factors of concern: [checkbox value="nothing of note|Hx of denying the need for service contact|Hx of avoiding of service contact|non-responsiveness to pharmacological treatment|non-responsiveness to psychosocial interventions|personality structure|Hx of substance abuse|recent discharge from a psychiatric facility|chronic stressors|a history of self-harm|a history of previous suicide attempts|previous hospitalization for suicidality|previous hospitalization for self-harm|Hx of psychiatric illness|unstable personality structure|a background of childhood adversity|having a family history of suicide|divorced|demographic - male - single age 35-64|problem-solving difficulties|Hx of impulsive behaviour|history of significant personal loss|Hx of reckless and self-endangering behaviors|absolutistic thinking|tunnel vision|limited capacity for self soothing|perfectionistic traits|struggles with sexual orientation|guns in the home|Pt is guarded around the issue of risk|access to abundant medications|chronic medical illness|chronic pain"]. However, its worth noting the following strengths that offer suicide risk protection: [checkbox value="treatment responsiveness|connectedness to individuals, family, community, and social institutions|problem-solving skills|coping skills|ability to adapt to change|a sense of purpose or meaning in life|personal beliefs that discourage self-injury|good social skills|ability to manage feelings of anger|good health|access to mental and physical health care|healthy fear of risky behaviours and pain|hope for the future and optimism|sobriety|medical compliance|a sense of the importance of health and wellness|impulse control|a strong sense of self-worth or self-esteem|a sense of personal control or determination|access to a variety of clinical interventions|help seeking behaviours|resiliency|expressed reasons for living|being married|being a parent|strong relationships|supportive friends|supportive family members|supportive spouse|opportunities to participate in and contribute to school or community projects and activities|living in a reasonably safe and stable environment|having restricted access to lethal means|sense of responsibility and duty to others|being a pet owner"] [textarea default=""]. The Pts suicide risk state is currently [checkbox value="elevated|at baseline"]. Factors affecting the Pts risk state include: [checkbox value="nothing of note|untreated mental illness|suicidal thinking|homelessness|personality disorder Sx|current stressors|lack of distress tolerance skills|lack of therapeutic alliance|access to lethal means|feels abandonned|feels socially undesirable|withdrawal from support groups|relationship breakdown|isolating and withdrawing from others|treatment non-compliance|abuse of substances|psycho-social stressors|feelings of hopelessness|feelings of anger|lack of vocational skills|unmet needs|external locus of control|rejection from peer group|recent loss of status|recent loss of ambitions|current suicidal plan|plan lethality|preparation behaviours|vocalising threat to suicide|rehearsal behaviours|recent suicide attempt|regrets not dying|acute mood disorder|increased substance abuse|mood lability|suicide command hallucinations|insomnia|persistent nightmares|unremitting pain|persistent distress|persistent agitation|tearfulness|guarded and difficult to assess|withdrawal from services|comorbid MH concerns|feelings of hopelessness|severe anhedonia|severe depression|loss of self-esteem|feelings of shame|feeling intolerably alone|feeling trapped|no reasons for living|loss of purpose and meaning|increased impulsivity|increased recklessness|increased anger|seeking revenge|recent violent behaviours|final act behaviours|stalking|intense jealousy over ex|recent loss of relationship|loss of social support|recent discharge from MH-IPU|loss of job|increasing financial pressure|loss of status|recent suicide of a loved one|declining health|pending legal issues|pending criminal charges|feeling victimised"] [textarea default=""]. Available support resources include: [textarea default=""] Foreseeable risk changes of concern include: [textarea default=""][/conditional] Summary of progress since admission: [select value="symptoms are worsening|variable|static|slow|fair|good|exceptional"]. Pts view of progress since admission: [select value="unable to rate|much less than expected|somewhat less than expected|acheived expected outcomes|somewhat more than expected|much more than expected"]. PLAN and ACTION Medications administered today: [textarea default="nil"] Recommended action to support recovery: [checkbox value="continue with the current treatment and supports|consider psychiatric medication|better medication management|a medication review|enhanced motivation to change|increased psychosocial support|increased caloric intake|weightloss|excercise|healthy lifetyle choices|more social contact|acute symptom monitoring|setting realistic expectations for recovery|family, friends and partner education|carer support|support to attend MH appointments|transport support|reduce hostility towards MH services|work collaboratively within the legal obligations of involuntary treatment|learn emotional coping skills|discuss shared goals to better work collaboratively|motivate Pt to accept supports|refer to therapy for work on PTSD and stress related concerns|challenge unhelpful thoughts|boost low-self esteem|reduce work stress|solve housing problems|address homelessness|reduce over-burdening debt|a more flexible self-concept|reduce financial stress|help Pt move away from identifying with a sick role|support around ongoing legal problems|employment support|more education|vocational training|getting a job|returning to work|TAFE|university|continue with formal education|dietician input|attending medical appointments|childcare support|pregnancy support|reduced discord with family|reduced interpersonal conflict|reduce or cease substance use|improved care coordination|enhance self-efficacy|address sexual difficulties with professional support|improve medication adherence and compliance|therapy around rigid psychological defenses|support regarding relationship problems|challenge unhelpful thinking style|reduce feelings of hopelessness|education to bring awareness of the problem|enhance willingness to take an active role in recovery|explore internal locus of control|reduce secondary gains from the sick role|enhance motivation to change|reduce severity of MH symptoms|reduce severity of medical symptoms|more support around complex comorbidities|NDIS support|Pt to attempt recommended homework|book Pt to attend a psychiatry review|book Pt to have contact with me|encouraged Pt to attend counselling|referred Pt to drug and alcohol services|contact housing services|contact centrelink|encourage continuing education|apply for a CTO|contact family or carer to discuss welfare concerns|refer to a CMO for psychosocial support|refer Pt to the acute care team for monitoring|discuss finances with Trustee and Guardian|raise concerns for welfare with carer|refer Pt to community support services|encouraged Pt to attend medical apt|plan a complex care meeting|encouraged Pt to exert choice and control|encouraged Pt to present to ED|contact police and report welfare concerns|disability services referral|urged Pt to consider the impact of substance misuse"] [textarea default=""] Risk plan and action: [checkbox value="No need for further action today|I reminded the patient to call MHAL 1800011511 if needed, and urged them to present to the ED or call 000 in a crisis|encouraged Pt to contact ACS after hours|Pt and I agreed to a harm minimization approach by removing access to lethal means|I called emergency services and reported my concerns|I called the MHAL and reported my concerns|I made a notification of suspected abuse to FACS|I contacted police to report safety concerns"] [textarea default=""] Next apt: [textarea default=""].
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