Psychiatric Assessment IN PROGRESS

ASSESSMENT
[checkbox name="iniass" value="" memo="Initial Assessment"][conditional field="iniass" condition="(iniass).is('')"]Patient presents with [select value="symptoms of|well managed|moderately managed|poorly managed"] [checkbox value="depression|anxiety|sleep disturbance|psychosis|substance abuse|cognitive impairment|impulsivity|mood lability|alcohol dependence|opiate dependence|autism spectrum disorder"][textarea memo="other" default="" rows="1"] [select value="likely caused by|likely exacerbated by|likely the result of"] [checkbox value="their cancer diagnosis|their cancer treatment|their unmanaged depressive disorder|their unmanaged anxiety disorder|their unmanaged bipolar disorder|interpersonal/family conflict|current psychopharmaceutical intervention|current psychotherapy|current psychosocial support systems"][textarea memo="other" default="" rows="1"]. Patient would benefit from [checkbox value="initiation of psychopharmaceutical intervention|continued psychopharmaceutical intervention|adjustments to current psychopharmaceutical intervention|initiation of psychotherapy|continuation of current psychotherapy|engaging in grief therapy|engaging in CBT|engaging in family therapy|enhanced psychosocial supports|increasing personal time and self-care"]. [/conditional][conditional field="prognosis" condition="(prognosis).is('')"]Prognosis is [select value="good|fair|poor"] considering the patient [select value="remains adherent to|actively engages in|is not currently responding to|is not currently willing to engage in recommended|has chronically had poor response to"] medication/therapy to address [textarea memo="target of treatment" rows="1"][checkbox value=" and whether they are able to engage constructively with social supports"]. [checkbox name="barrier" value="Barriers to success include: "][/conditional][conditional field="barrier" condition="(barrier).is('Barriers to success include: ')"][checkbox value="current apprehension to engage in psychopharmaceutical intervention|current apprehension to engage in structured psychotherapy|current emotional distress of recent cancer diagnosis|limited social supports|dysfunctional interpersonal relationships"][textarea memo="barriers" rows="1"].[/conditional] [conditional field="prognosis" condition="(prognosis).is('')"][checkbox name="strength" value="Patient strength for success include: "][/conditional][conditional field="strength" condition="(strength).is('Patient strength for success include: ')"][checkbox value="expression of willingness to engage in treatment recommendations|positive social supports|are well connected with outpatient supports|history of actively engaging in mental-health treatment"][textarea memo="strengths" rows="1"].[/conditional] [textarea rows="5"][checkbox name="folass" memo="Followup Assessment Statement" value=""][conditional field="folass" condition="(folass).is('')"][checkbox name="anxass" memo="anxiety" value=""][checkbox name="depass" memo="depression" value=""][checkbox name="addass" memo="attention/concentration" value=""][checkbox name="bipass" memo="bipolar" value=""][checkbox name="slpass" memo="sleep" value=""][checkbox name="pndass" memo="paranoia" value=""][checkbox name="halass" memo="hallucinations" value=""][/conditional][conditional field="anxass" condition="(anxass).is('')"]

Patient's anxiety presents as [select value="much improved|slightly improved|the same|slightly worse|significantly worse|"][text size="20"].  [select value="Improvement|Exacerbation|Stability|Lack of improvement"] of anxiety is likely due to [select value="positive response to medications|situational stressors|nonresponse to medication adjustments|adverse response to medication adjustments|unwillingness to engage with treatment recommendations|"][textarea rows="2"].  [select value="Will continue utilizing |New prescription of |Will increase |Will decrease |"][textarea rows="1"].  [checkbox value="Will continue encouraging participation in individual counseling to develop better coping skills for anxiety.  "][checkbox value="Will continue encouraging engagement in treatment of sleep apnea to better improve anxiety.  "][/conditional][conditional field="depass" condition="(depass).is('')"]

Patient's depression appears to be [select value="much improved|slightly improved|the same|slightly worse|significantly worse|"][text size="20"].  [select value="Improvement|Exacerbation|Stability|Lack of improvement"] of depression is likely due to [select value="positive response to medications|situational stressors|nonresponse to medication adjustments|adverse response to medication adjustments|unwillingness to engage with treatment recommendations|"][textarea rows="2"].  [select value="Will continue utilizing |New prescription of |Will increase |Will decrease |"][textarea rows="1"].  [checkbox value="Will continue encouraging participation in individual counseling to adjust behaviors to better improve mood and identify potential sources of depression.  "][checkbox value="Will continue encouraging engagement in treatment of sleep apnea to better improve depression.  "][/conditional][conditional field="bipass" condition="(bipass).is('')"]

Patient's mood disorder appears to be [select value="much improved|slightly improved|the same|slightly worse|significantly worse|"][text size="20"].  Depressive symptoms have [select value="decreased|increased|remained stable|resolved|"][text size="20"][select value=" and mania| and irritability|"][text size="20"][select value=" has decreased in frequency| has increased in frequency|  has been less of an issue| has remained the same|  continues to be a problem|"][textarea rows="1"].  [select value="Improvement|Exacerbation|Stability|Lack of improvement"] of mood disorder is likely due to [select value="positive response to medications|situational stressors|nonresponse to medication adjustments|adverse response to medication adjustments|unwillingness to engage with treatment recommendations|"][textarea rows="2"].  [select value="Will continue utilizing |New prescription of |Will increase |Will decrease |"][textarea rows="1"].  [checkbox value="Will continue encouraging participation in individual counseling to adjust behaviors to better improve mood and utilization of coping mechanisms.  "][checkbox value="Will continue encouraging engagement in treatment of sleep apnea to better improve depression.  "][/conditional]
[conditional field="addass" condition="(addass).is('')"]

Attention and concentration are reported to be [select value="much improved|slightly improved|the same|slightly worse|significantly worse|"][text size="20"].  [select value="Improvement|Exacerbation|Stability|Lack of improvement"] of attention and concentration is likely due to [select value="positive response to medications|improved sleep|resolution of comorbid psychiatric symptoms|situational stressors|nonresponse to medication adjustments|adverse response to medication adjustments|unwillingness to engage with treatment recommendations|"][textarea rows="2"].  [select value="Will continue utilizing |New prescription of |Will increase |Will decrease |"][textarea rows="1"].  [checkbox value="Will continue encouraging participation in individual counseling to adjust behaviors to better cope with inattention and difficulty with concentration.  "][checkbox value="Will continue encouraging engagement in treatment of sleep apnea to better improve cognition.  "][/conditional][conditional field="pndass" condition="(pndass).is('')"]

Patient's paranoia is [select value="much improved|slightly improved|fairly stable|still present but not problematic|a continued problem|somewhat worse|significantly worse|"][text size="20"].  [select value="Improvement|Exacerbation|Stability|Lack of improvement"] of paranoid thoughts is likely [select value="a positive response to medication|situational stressors|nonresponse to medication adjustments|adverse response to medication adjustments|unwillingness to engage with treatment recommendations|"][textarea rows="2"].  [select value="Will continue utilizing |New prescription of |Will increase |Will decrease |"][textarea rows="1"].  [checkbox value="Current level of paranoid thoughts is likely a part of baseline cognition, and resolution may not be possible.  "][/conditional][conditional field="halass" condition="(halass).is('')"]

Patient's perceptual disturbances of [select value="auditory hallucinations|visual hallucinations|auditory and visual hallucinations|"][text size="20"] are [select value="much improved|slightly improved|fairly stable|still present but not problematic|a continued problem|somewhat worse|significantly worse|"][text size="20"].  [select value="Improvement|Exacerbation|Stability|Lack of improvement"] of perceptual disturbances is likely [select value="a positive response to medication|situational stressors|nonresponse to medication adjustments|adverse response to medication adjustments|unwillingness to engage with treatment recommendations|"][textarea rows="2"].  [select value="Will continue utilizing |New prescription of |Will increase |Will decrease |"][textarea rows="1"].  [checkbox value="Current level of hallucinations is likely a part of baseline cognition, and resolution may not be possible.  "][/conditional][conditional field="slpass" condition="(slpass).is('')"]

Patient's sleep is reported to be [select value="much improved|slightly improved|the same|slightly worse|significantly worse|"][text size="20"].[select value="  Time until sleep initiation has |"][select value="decreased|become less of an issue|increased|remained difficult|remained a non-issue|resolved|"][text size="20"][select value=" and nighttime waking| and they are able to stay asleep through the night"][text size="20"][select value=" has decreased in frequency| has increased in frequency|  has been less of an issue| continues to be an issue|"][textarea rows="1"].  [select value="Improvement|Exacerbation|Stability|Lack of improvement"] of disordered sleep is likely due to [select value="positive response to medications|situational stressors|nonresponse to medication adjustments|adverse response to medication adjustments|unwillingness to engage with treatment recommendations|"][textarea rows="2"].  [select value="Will continue utilizing |New prescription of |Will increase |Will decrease |"][textarea rows="1"].  [checkbox value="Will continue encouraging adherence to positive sleep hygiene techniques.  "][checkbox value="Will continue encouraging engagement in treatment of sleep apnea to better improve quality of sleep.  "][textarea rows="2"][/conditional]

GOALS

[checkbox name="Depgoal" value="-Patient will report score on PHQ-9 of "][conditional field="Depgoal" condition="(Depgoal).is('-Patient will report score on PHQ-9 of ')"][select value="8|5|6|7|8|9|10|11|12|13|14|15"] or less within [select value="3 months|1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"][checkbox name="Anxiety" value="
-Patient will report score on GAD-7 of "] [conditional field="Anxiety" condition="(Anxiety).is('
-Patient will report score on GAD-7 of ')"][select value="8|5|6|7|8|9|10|11|12|13|14|15"] or less within [select value="3 months|1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"][checkbox name="Nicotine" value="
-Patient will reduce nicotine intake by 50% within "][conditional field="Nicotine" condition="(Nicotine).is('
-Patient will reduce nicotine intake by 50% within ')"][select value="1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"][checkbox name="Sleep" value="
-Patient will experience 6+ hours of uninterrupted sleep per night within "][conditional field="Sleep" condition="(Sleep).is('
-Patient will experience 6+ hours of uninterrupted sleep per night within ')"][select value="3 months|1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"][checkbox name="Cognition" value="
-Patient will report impact of cognitive impairment as mild/resolved within "][conditional field="Cognition" condition="(Cognition).is('
-Patient will report impact of cognitive impairment as mild/resolved within ')"][select default="3" value="3 months|1 month|2 months|3 months|4 months|5 months|6 months"]: Initiated [date default="today"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][/conditional][textarea rows="1"]