Psychiatry
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Mental Status Examination & Other

[checklist name="details" value="presented on time for scheduled counseling session|verbally consented to telemental health counseling|no video available for session|engaged and cooperative|avoidant or disengaged"]

Mood:
[select name="Mood" value="euthymic|anxious|depressed|hypomanic|angry|agitated|frustrated|grief/loss|restless"]

Speech:
[select name="Speech" value="WNL|soft|hurried|loud|forced"]

Behavior:
[select name="Behavior" value="WNL|agitated|tired/fatigued|depressed|anxious"]

Affect:
[select name="Affect" value="WNL-congruent|flat|labile|blunted"]

Thought Content:
[select name="Thought" value="WNL|tangential|rapid-fire|delusions|concrete|obsessive|preoccupied"]

Risk for Suicide or Self-harm:
[checkbox name="harm" value="none identified|Hx self-harm|Hx SI|Hx previous suicide attempt(s)|denies SI/HI|denies intent|denies plan|denies means|endorses passive SI/HI|endorses active SI/HI|endorses plan|endorses intent|endorses means|self-harm:passive|self-harm:active"]

Protective Factors:
[checkbox name="protective" value="Social support|Family|Future-oriented|Rx compliance|Tx compliance|Other protective factor(s)|N/A"]

Risk Assessment:
[select name="risk" value="low|moderate|HIGH"]

Progress:
[select name="progress" value="Actively making progress|Making some progress|Planning|No observable progress|Not engaged in session|Not engaged in therapy"]

Interventions:
1. [select name="intervention_1" value="Processed thoughts and feelings since last visit|Validated and normalized|CBT-Cognitive Restructuring|Person-centered|ACT|Creative visualization|Breathing exercise|Grounding exercise|Case management|Psychoeducation|Other(see below)"]
2. [select name="intervention_2" value="Processed thoughts and feelings since last visit|Validated and normalized|CBT-Cognitive Restructuring|Person-centered|ACT|Creative visualization|Breathing exercise|Grounding exercise|Case management|Psychoeducation|Other(see below)"]
3. [select name="intervention_3" value="Processed thoughts and feelings since last visit|Validated and normalized|CBT-Cognitive Restructuring|Person-centered|ACT|Creative visualization|Breathing exercise|Grounding exercise|Case management|Psychoeducation|Other(see below)|N/A"]


Topics Discussed:
[textarea name="variable_1" default="1. "]

Plan:
[select name="variable_1" value="Continue Counseling|Continue Consult|d/c - non-compliance|d/c - referral|d/c - no further services recommended at this time"]
Mental Status Examination & Other



Mood:


Speech:


Behavior:


Affect:


Thought Content:


Risk for Suicide or Self-harm:


Protective Factors:


Risk Assessment:


Progress:


Interventions:
1.
2.
3.


Topics Discussed:


Plan:

Result - Copy and paste this output:

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