MH – Comprehensive SOAPNOTE with risk Ax

S. 
[text default="Name"] is a [text default="X year old"] [select value="female|male"] [select value="voluntary|involuntary"] Pt, complaining of [textarea default=""].

[textarea default="History of Present Illness"]

[textarea default="Purpose of Visit"]

[textarea default="Patient Report"]

O.

The patient, a [text default="X year old"] [select value="female|male"], who presents with an appearance [select value="befitting|exceeding|falling short of"] their stated years, is of [select value="an average|a slender|a petite|a robust|tall"] stature and appears to be [select value="proportionate in weight|somewhat corpulent|somewhat gaunt|noticeably portly|distinctly undernourished"] relative to the build.
The patients grooming, hygiene, and self-care exhibit a standard [checkbox value="befitting social norms|somewhat neglected|remarkably meticulous"]. The attire is [checkbox value="neat, clean, casual, and suitable for the occasion|clean, though unremarkable|unseemly for their age|incongruent with the occasion|exceedingly fastidious|disordered|sullied|eccentric|malodourous"], and the posture is [checkbox value="easeful|prone in bed|seated in bed|stiff|constrained|tight|bowed|self-assured|belligerent|tense|collapsed|knees drawn up to the chest"].

In terms of engagement, [text default="NAME"] presents as [checkbox value="displaying a generally positive and cooperative demeanor|obliging, yet reserved|overly familiar and lacking respect for boundaries|guarded and challenging to engage|hostile and presenting a threat|anxious and somewhat uncontainable|dependent and overwhelmed|bitter and full of grievances|dramatic, often exaggerating concerns|ambivalent and enigmatic|disinterested in proceedings|frivolous and inclined to jest|passively resistant and detached|hostile and presenting a threat|sarcastic and taunting in nature|foolish and evasive|flirtatious to an inappropriate degree|demanding and seldom satisfied|paranoid, perceiving potential harm|elusive and challenging to assess|profoundly affected by mental health symptoms, hindering engagement"], and the [checkbox value="facial|vocal"] expression is [checkbox value="smiling|relaxed|neutral|impenetrable|anxious|worried|sorrowful|expressionless|irate|suspicious|arrogant|scowling|drowsy]. During this encounter, the patient's attention is [select value=appropriately focused on the author|fixated on irrelevancies|easily distractible|highly vigilant|preoccupied with internal thoughts] and the patient is [checkbox value=oriented to person, place, and time|generally oriented but|affected by auditory hallucinations|affected by visual hallucinations|affected by both auditory and visual hallucinations|influenced by delusions and unrealistic preoccupations|under the influence of substances|disoriented to person|disoriented to place|disoriented to time].

The quality of the patient's speech is characterized as [checkbox value="crisp and well-articulated|exhibiting selective mutism|entirely nonverbal|uniformly monotonous|audibly loud|succinct|deficient in detail|excessively verbose|indistinct mumbling|speaking in hushed tones|notably quiet|experiencing pressured speech|engaging in ranting|prone to rambling|incoherent babbling|showing signs of aphasia|misaligned with current mood and situational context"].
The thinking style is [checkbox value="logical and adaptable|inflexible and literal|prone to personalizing|persecutory|indecisive|unrealistically optimistic|impeded by referential thinking|entertaining magical thoughts of influence and control|severely distorted|confabulatory|hampered by memory recall issues|inclined to provide irrelevant details|meandering among various topics|prone to rapid shifts in thought|filled with racing and unrealistic ideas|occasionally blocking|circular and repetitive in theme|fixated on over-valued ideas"].

Unprompted, the patient voiced concerns regarding: [checkbox value="no specific mental health issues|medicational queries|a request for psychiatric review|enquiry about the forthcoming appointment date|medication side effects|prescription details|self-regard quandaries|thoughts of self-termination|self-injurious behaviors|parenthood-related anxieties|fiscal distress|perplexing cogitations|educational dilemmas|physical health quandaries|levels of vigor|patterns of slumber|residential circumstances|employment-related worries|dietary customs|concerns regarding body mass|obsessive thoughts|mood irregularities|troubles with emotional regulation|familial discord|stressors linked to employment|experiences of bereavement and loss|illnesses|an absence of a defined societal role|anxieties about body image|neighborly frictions|interactions with support personnel|memories causing distress|issues related to Community Treatment Orders|substance consumption|legal predicaments|anxieties related to offspring|parental challenges|grievances about the provided service and its quality|challenges during transitions|relations with peers|processes of mourning|difficulties in romantic relations"] [textarea default=""] which appeared [checkbox value="suitable|acceptable|grounded in reality|unsuitable|overstated|naive|impractical"] to the author.

The patient's cognitive functioning reveals it to be [checkbox value="intact and otherwise unremarkable|adversely affected by symptoms of mental illness|hampered by poor memory|undermined by attention difficulties|compromised in understanding and comprehension|diminished by a reduced level of consciousness and general alertness|influenced by substance use|impacted by medication"] [textarea default=""].
In light of the patients grasp of the purpose behind our interaction today,  insight is perceived as [select value="unimpaired|partial|limited"], and judgement is evaluated as [select value="unimpaired|partial|limited"].

Upon inquiring about self-harm, suicide, and potential harm to others, the patient [checkbox value="refuted any such tendencies|revealed occasional thoughts of self-harm without suicidal ideation|admitted to thoughts of harming others but without intent|acknowledged thoughts of causing harm to others with a determined intent to act|confirmed prior acts of aggression towards others|confessed to sporadic self-harm thoughts accompanied by suicidal ideation, yet without definitive plans or earnest intent|reported engaging in non-suicidal self-injury|voiced indistinct thoughts of ending their life, albeit with no serious intent|shared intense thoughts of suicide lacking in serious intent|conveyed thoughts of suicide, inclusive of a plan, but lacking a resolute intent|expressed a potent intent to commit suicide, yet without a specified plan|unveiled a determined intent and a devised plan for suicide|expressed an immediate crisis of suicidal urgency and a need not to be left unattended"].

A. 

Impression: The afflictions besetting the patient, encompassed [checkbox value="acute mental health distress|complex mental health and psychosocial complications|a developmental anomaly|schizophrenia spectrum disorder|a situational quandary|acute yet indistinct mental health tribulations|a risk of self-harm|a propensity for violence|a danger to reputation|financial jeopardy|non-suicidal self-injury|bipolar dispositions|a depressive state|an anxious disposition|obsessive-compulsive tendencies|trauma and stress-related turmoil|a dissociative condition|a somatic symptom conundrum|feeding and eating related disorders|elimination related dilemmas|sleep-wake disturbances|sexual dysfunctions|gender incongruence|impulse control challenges|substance-related difficulties|neurocognitive disorders|personality disorders"] [textarea default=""], appear to be [select value="in a state of remission|of mild severity|of moderate severity|of grave severity"], which exert a [select value="negligible|minimal yet at times marked|persistent and occasionally significant|continuously substantial and often overwhelming"] influence on the patients overall existence.

Pts concerns are 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"].

From our contact today, the patients symptoms appear to be [select value="stable|improving|deteriorating"] since [select value="the initial referral|our last clinical encounter"]. The overall clinical progress is [select value="unchanged|gradual|fairly steady|quite favorable"], and the global assessment of functioning is: [checkbox value="100-99 Superior functioning across a broad spectrum of activities, with an absence of symptoms.|90-81 No or minimal symptoms, excellent functioning in all areas, engaged and active in a wide variety of activities, socially effective, life generally satisfying, facing only everyday problems or concerns.|80-71 If symptoms are present, they are brief and expected reactions to psychosocial stressors.|70-61 Some mild symptoms or some difficulty in social, occupational areas, but generally functioning well, maintaining meaningful interpersonal relationships.|60-51 Moderate symptoms or moderate difficulty in social, occupational functioning.|50-41 Serious symptoms or any serious impairment in social, occupational spheres.|40-31 Some impairment in reality testing or communication, or major impairment in several areas of life.|30-21 Behavior significantly influenced by delusions or hallucinations, or serious impairment in communication, judgment, or nearly all areas of functioning.|20-11 Some risk of harm to self or others, or occasional failure in personal hygiene, or gross impairment in communication.|10-1 Persistent risk of severe harm to self or others, or persistent inability to maintain minimal personal hygiene, or serious suicidal act with clear expectation of death.|0 Insufficient information to assess.|unable to rate"].

Based on todays contact, ongoing areas of concern are: [checkbox value="no notable issues|self-care and appearance|behavioral challenges|self-esteem and self-concept issues|rapport and attitude|mood and affect|perceptual disturbances|the patients style of thinking|content of thoughts and ideas expressed by the patient|orientation to reality|cognitive functioning|insight and judgement|suicidal tendencies|self-harming behaviors|potential for harm to others|overall welfare"] [textarea default=""].

Enduring factors impacting the patients overall mental health recovery: [checkbox value="no notable factors|severity of symptoms|suboptimal response to medication|a lack of social support|a passive disposition|a hostile demeanor|entrenched delusions|challenging psychosocial circumstances|disadvantaged cultural background|overly emphasized personal beliefs|an unfavorable social reputation|a tendency to sever relationships|ongoing legal issues|overwhelming debts|transient lifestyle|deficient emotional coping mechanisms|limited educational background|problems with impulsivity|cultural dislocation|a history of being subjected to violence|a lack of psychological awareness|limited capacity for self-reflection|poor insight|residing in a challenging social environment|a history of childhood adversity|a history of being victimized|limited employment skills|poverty|ongoing medical issues|physical disability|social isolation|an external locus of control|complications related to upbringing|chronic medical conditions|extreme personal convictions|instability of personality|difficulties associated with life transitions|intellectual and cognitive challenges"] [textarea default=""].

[comment memo="Kindly attend to -- Suicide Risk Assessment -- should concerns of immediate suicide risk be present"]

[checkbox name="suic" value="-- Suicide Risk Assessment --"][conditional field="suic" condition="(suic).is('-- Suicide Risk Assessment --')"]

The estimation of the patient's suicide risk status is: [checkbox value="exceeding|equivalent to"] that of the general populace.
Enduring concerns warranting attention include: [checkbox value="none of note|A history of eschewing the necessity for service engagement|A tendency to shun service contact|An unyielding nature to pharmacological remedies|A lack of response to psychosocial stratagems|Intrinsic personality constructs|A chronicled history of substance misuse|Recent egress from psychiatric care|Persistent life stressors|An established history of self-injurious behavior|Prior attempts at self-termination|Antecedent hospitalization owing to suicidal tendencies|Former hospital admissions due to self-harm|A chronicled psychiatric malady|A volatile personality makeup|Early life adversities|A familial lineage of suicide|Marital dissolution|Demographic specifics - male, solitary, aged 35-64|Challenges in problem resolution|A record of impetuous conduct|Experiences of significant personal bereavement|Historical engagement in hazardous and self-imperiling conduct|A proclivity for absolutist thinking|A propensity for myopic perspective|A scant ability for self-comfort|Perfectionist inclinations|Difficulties regarding sexual identity|The presence of firearms in the domicile|A reticent attitude concerning risk discussion|Ready access to a plethora of medications|A continuing medical affliction|Persistent pain afflictions"].

Certainly, its worth recognizing the following strengths that fortify against the risk of self-harm: [checkbox value="a responsive nature to treatment|ties to individuals, kin, community, and societal institutions|aptitude in solving problems|skills in coping|a capacity to adjust to changes|a sense of purpose or meaning in existence|personal convictions that dissuade self-injury|proficient social interactions|a capability to manage feelings of ire|robust health|access to mental and physical healthcare|a healthy trepidation of hazardous behaviors and pain|aspirations for the future and an optimistic outlook|a state of sobriety|adherence to medical advice|a recognition of the value of health and well-being|control over impulses|a robust sense of self-worth or self-esteem|a feeling of personal agency or determination|availability of diverse clinical interventions|propensity to seek help|resilience|articulated reasons for continuing to live|being wedded|parenthood|solid relationships|supportive companions|supportive kin|a supportive partner|opportunities for participation and contribution in educational or communal ventures|residing in a relatively secure and stable environment|limited access to means of self-harm|a sense of obligation and duty towards others|being a caretaker of pets"] [textarea default=""].

The patient's current state of suicide risk is [checkbox value="heightened|at its usual level"].
Factors influencing the patients risk status include: [checkbox value="no significant factors|untreated mental disorders|suicidal contemplations|absence of a home|traits of a personality disorder|present stressors|a deficit in tolerance of distress|an absence of a therapeutic alliance|availability of lethal means|feelings of abandonment|perceived social undesirability|detachment from support networks|dissolution of relationships|tendency to isolate and withdraw from social interaction|noncompliance with treatment|misuse of substances|psychosocial stressors|sensations of despair|feelings of rage|a lack of vocational competencies|unfulfilled needs|an external locus of control|rejection from ones peer group|a recent diminution in status|abandoned aspirations|a current plan for self-harm|the lethality of the plan|preparatory actions|expressions of a threat to self-harm|practice attempts|a recent endeavor at self-harm|regrets over survival|an acute mood disorder|escalated substance misuse|instability of mood|hallucinations commanding self-harm|insomnia|unending nightmares|unabating pain|continuous distress|unrelenting agitation|frequent tearfulness|a guarded and challenging demeanor in assessments|withdrawal from healthcare services|coexisting mental health issues|feelings of utter hopelessness|profound anhedonia|severe depressive states|a loss of self-regard|sensations of humiliation|feelings of intolerable solitude|a sensation of entrapment|an absence of reasons to continue living|a loss of purpose and significance|an increase in impulsiveness|an increase in recklessness|an increase in anger|motives of vengeance|recent aggressive behaviors|final act behaviors|stalking behaviors|intense envy over former partners|a recent end of a relationship|a loss of social support|recent discharge from a mental health inpatient unit|a loss of employment|mounting financial strains|a loss of social standing|recent bereavement by suicide|declining physical health|impending legal matters|forthcoming criminal charges|feelings of being victimized"] [textarea default=""].

Available support resources encompass: [textarea default=""]

Foreseeable risk changes of concern comprise: [textarea default=""][/conditional]

A summary of progress since admission: [checkbox value="symptoms have deteriorated|variable|unchanged|improving slowly|are fairly improved|are notably improved|are exceptionally improved'].

The patients perspective on progress since admission: [select value="unable to assess|far below expectations|slightly below expectations|met expected outcomes|exceeded expectations slightly|far exceeded expectations"].

PLAN and ACTION

Recommended actions to bolster recovery include: [checkbox value="persevere with the current treatment and support regimen|contemplate psychiatric medication|improve medication management|conduct a medication review|foster enhanced motivation for change|amplify psychosocial support|increase caloric consumption|pursue weight loss|engage in physical exercise|adopt healthier lifestyle choices|seek more social interaction|monitor acute symptoms closely|set realistic recovery expectations|educate family, friends, and partners|provide carer support|assist with attendance at mental health appointments|offer transport support|diminish hostility towards mental health services|collaborate within the bounds of involuntary treatment requirements|acquire emotional coping skills|engage in dialogues about shared goals for collaborative work|motivate the patient to accept support|refer for therapy addressing PTSD and stress-related concerns|challenge counterproductive thoughts|enhance self-esteem|alleviate work-related stress|resolve housing issues|address homelessness|ease overwhelming debt|cultivate a more adaptable self-concept|alleviate financial stress|assist the patient to move beyond the sick role identification|support around ongoing legal issues|provide employment support|offer further education|provide vocational training|aid in job acquisition|assist with return to work|encourage continuation of formal education|involve dietician consultation|ensure medical appointment attendance|offer childcare support|provide pregnancy support|reduce family discord|mitigate interpersonal conflicts|aim to reduce or cease substance use|improve care coordination|enhance self-efficacy|address sexual issues with professional support|improve medication adherence and compliance|therapy for rigid psychological defenses|support around relationship problems|challenge unhelpful thinking styles|reduce feelings of hopelessness|educate to increase problem awareness|enhance active recovery role willingness|explore an internal locus of control|minimize secondary gains from the sick role|boost change motivation|mitigate mental health symptom severity|alleviate severity of medical symptoms|augment support for complex comorbidities|utilize NDIS support|encourage patient to undertake recommended homework|schedule a psychiatry review|book patient contact with me|encourage counseling attendance|refer to drug and alcohol services|contact housing services|liaise with Centrelink|promote continuing education|apply for a Community Treatment Order|discuss welfare concerns with family or carer|refer to a Community Management Organization for psychosocial support|refer patient to the acute care team for monitoring|discuss finances with Trustee and Guardian|convey welfare concerns to carer|refer patient to community support services|encourage attendance at medical appointments|organize a complex care meeting|urge patient to exercise choice and control|advocate for emergency department presentation|notify police of welfare concerns|refer to disability services|urge the patient to consider the impact of substance misuse"] [textarea default=""].
S.
is a Pt, complaining of
.







O.

The patient, a , who presents with an appearance their stated years, is of stature and appears to be relative to the build.
The patients grooming, hygiene, and self-care exhibit a standard . The attire is , and the posture is .

In terms of engagement, presents as , and the expression is . During this encounter, the patient's attention is and the patient is .

The quality of the patient's speech is characterized as .
The thinking style is .

Unprompted, the patient voiced concerns regarding:
which appeared to the author.

The patient's cognitive functioning reveals it to be
.
In light of the patients grasp of the purpose behind our interaction today, insight is perceived as , and judgement is evaluated as .

Upon inquiring about self-harm, suicide, and potential harm to others, the patient .

A.

Impression: The afflictions besetting the patient, encompassed
, appear to be , which exert a influence on the patients overall existence.

Pts concerns are characterised by these symptoms: .

From our contact today, the patients symptoms appear to be since . The overall clinical progress is , and the global assessment of functioning is: .

Based on todays contact, ongoing areas of concern are:
.

Enduring factors impacting the patients overall mental health recovery:
.

Kindly attend to -- Suicide Risk Assessment -- should concerns of immediate suicide risk be present



A summary of progress since admission: .

The patients perspective on progress since admission: .

PLAN and ACTION

Recommended actions to bolster recovery include:
.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.69, 61 form elements, 222 boilerplate words, 4 text boxes, 14 text areas, 26 checkboxes, 15 drop downs, 1 comments, 1 conditionals, 601 total clicks
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