Psychiatric Comprehensive Evaluation-PMHNP

Psychiatric Comprehensive Evaluation-PMHNP

History: [textarea memo="Very pertinent history, otherwise leave blank" cols="31" rows="1"]

Chief Complaint: [textarea memo="In patient's own words" default="Auto-populated in EMR" cols="31" rows="1"]

Source of Information and their reliability:
[textarea default="Patient:\nAdmission Note:\nJail Records:" cols="51" rows="4"]

History of Present Illness:
[textarea memo="Look at Admission Note" default="Pull from AO" cols="51" Rows="4"]

ROS:
[textarea memo="Look at Admission Note" default="Pull from AO" cols="51" Rows="4"]

Physical Exam:
[textarea memo="Look at Admission Note" default="Pull from AO" cols="51" Rows="4"]

--Mental Status Examination--

Appearance/Behavior: 
-general: [select value="Alert and oriented in all spheres|obtunded|disoriented|unknown"].[select value="Appears to be of chronological age|Appears younger than chronological age|Appears older than chronological age|unknown"].
-accessibility:[select value="cooperative|friendly|uncooperative|irritated but not to the level of anger|angry|hostile|alert|confused|hostile|silent|inappropriate boundaries|seductive|playful|ingratiating|evasive|guarded|sullen|manipulative|contemptuous|demanding|withdrawn|"][text].
-grooming: [select value="Average/WNL|well-groomed|poorly groomed|meticulously groomed|unknown"].
-clothing: [select value="clean|dirty|unkempt|neat|tidy|meticulous|worn out|skillfully applied|unconventional|fashionable|unknown|professional"],[select value="appropriate for season| inappropriate to season|unknown"],[select value="wearing issued sweatshirt and pants| inappropriately worn clothing|unknown"].
-hygiene: [select value="clean|unbathed|dirty|body odor|smells of alcohol|unknown"].
-Body habitus: [select value="average height|tall|short|unknown"],[select value="average weight|thin|overweight|obese|underweight|unknown"].
-facial expression: [select value="casual(normal)|bland|flat|mobile(rapid changes)|angry|unknown"]. Patient is [select value="wearing a a face mask|not wearing a face mask|"].
-Signs of distress: [select value="in no distress|in mild psychological distress|in moderate psychological distress|in acute psychological distress"].
-Eye contact: [select value="eye contact good|eye contact fair|eye contact avoidant|unknown"].
[text]

Psychomotor activity: 
-abnormal movements: [select value="none|grimaces|tics|twitches|foot tapping|rocking back and forth|hand wringing|ritualistic behavior|mannerisms|posturing|nail biting|chewing movements|echopraxia|tardive dyskinesia|catatonic|unknown"].
-Rate/gait: [select value="normal|hyperactive|slow|retarded|agitated|hesitant|propulsive|shuffling|dancing|ataxic|uncoordinated|unknown"].
-Coordination: [select value="normal/no problems|awkward|clumsy|agile|falling easily|needed assistance|bed ridden|uses wheelchair|uses walker|unknown"].
-Posture: [select value="quietly seated|relaxed|stooped|combative|hyperactive|agitated|rigid|stiff|shaky|slouched|bizarre movements|posturing|crouching|erect|restless|unknown"].
[text]

Speech: [select value="normal rate and volume|pressured|monotonous|quiet|emotional|loud|forgetful|whispering|yelling|accented|impoverished|neologisms|aphasia|global aphasia|Broca's aphasia|Wernicke's aphasia|dysarthia|preservation|sterotypy"].
Speech - clarity: [select value="clear|slurred|mumbled|lisping|stuttering|inaudible|incoherent|long pauses"].
Speech - quantity: [select value="within normal limits|responds only to questions|scant|mute|verbose|repetitive"].

Mood/Affect:
-Reported mood: [text]
-Observed mood: [select value="euthymic|expansive|euphoric|anxious|depressed|tearful|labile|flat|happy|sad|irritated|angry|enraged|guilty|"].
-Affect: [select value="euthymic|full range of affect|broad|appropriate|constricted|blunted|flat|labile|anhedonic|blunted|emotional withdrawal|excited"].
[text]


Cognition/Memory 
-overall functioning: [select value="within normal limits|grossly intact|below average|above average|short-term memory loss|long-term memory loss|amnesia|anterograde amnesia|retrograde amnesia| history of head trauma|transient global amnesia"]. [text]
-Orientation: [select value="orientated to person, place, time, and event|not orientated to person, place, time, and event|not orientated to place, time, or event|not orientated to time and event|not orientated to event|lethargic|obtundation|stupor|coma"].
-Abstraction: [select value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"].
-Attention & Concentration: [select value="Intact. Demonstrates the ability to focus and sustain their thoughts on a specific task/topic|Impaired. Unable to Demonstrates the ability to focus and sustain their thoughts on a specific task/topic"].
-Recent Memory:[select value="intact|impaired|Poor"].[text].
-Remote Memory:[select value="intact|impaired|Poor"].[text].

Thought Process: [select value="logical, relevant, and goal orientated|not logical, relevant, and goal orientated|past orientated|scattered|impoverished|racing thoughts|circumstantial|perservations|flight of ideas|illogical|hopeful|remorseful|enthusiastic|incoherent|neologism|distractable|tangential|overvalued ideas|excited|poverty of though|word salad|clang associations|slow reaction|rapid reaction|doubting|indecisive|blocking|spontaneous|pressured|"]. [text].

Perceptions: [select value="within normal limits|illusions|hallucinations|denationalization|derealization"]. [text]

Thought content: [select value="within normal limits|thought withdrawal|thought insertion|paranoia|thought broadcast|suspiciousness|grandiose delusions|somatic delusions|delusional guilt|nihilistic delusions|ideas of reference|ideas of inference|magical thinking"]. [text].

Insight: [select value="good|fair|poor"]. [select value=" |The patient demonstrates understanding and awareness of their current problems.|The patient does NOT demonstrate understanding and awareness of their current problems."][text].

Judgment: [select value="good|fair|poor"]. [select value=" |Demonstrates ability to make considerate decisions when performing a task based on their understanding of the current circumstances.|Does NOT demonstrate the ability to make considerate decisions when performing a task based on their understanding of the current circumstances."]
[text].


CAPACITY OF INFORMED CONSENT
Capacity of consent: [select value="|Has capacity|Does not have capacity|JA|AR"]


RATIONALE:
They [select name="variable_3" value="demonstrate|do NOT demonstrate"] the ability to communicate a choice, and can clearly indicate a preferred treatment option or deny treatment..
They [select name="variable_3" value="demonstrate|do NOT demonstrate"] the ability to understand the relevant information, and grasp the fundamental meaning of the information communicated to the patient regarding their medical condition and treatment.
They [select name="variable_3" value="demonstrate|do NOT demonstrate"] the ability to appreciate a situation and its consequences, and they acknowledge the medical condition and likely consequence of proposed treatment options and alternatives.
They [select name="variable_3" value="demonstrate|do NOT demonstrate"] the ability to reason rationally, and they are able to engage in a rational process of manipulating the relevant information.

Thus, the patient does [select name="variable_4" value="appear|NOT appear"] to have capacity to consent to medical treatment

---ASSESSMENT---
BEHAVIORAL RISK ASSESSMENT
1. Harm to others
Homicidality/bodily injury towards others: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|previous attempt|current ideation, no current plan or intent|current ideation and plan, no current intent|current ideation, plan, and intent"]. Patient is currently assessed to be at [select value="no|low|moderate|high"] risk of being a harm to others as evidenced by patient's self-report of [select value="not having any|having a"] homicidal ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of patient having a homicidal ideation/plan/intent: [textarea cols="20" rows="1" default= "No action taken."]

2.Harm to self
Suicide Risk Assessment: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|previous attempt|current ideation, no current plan or intent|current ideation and plan, no current intent|current ideation, plan, and intent"]. Patient is currently assessed to be at [select value="no|low|moderate|high"] risk for self harm as evidenced by patient's self-report of [select value="not having any|having a"] suicidal ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of patient having a suicidal ideation/plan/intent:[textarea cols="20" rows="1" default= "No action taken."]

Self-injurious behavior: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|previous attempt|current ideation, no current plan or intent|current ideation and plan, no current intent|current ideation, plan, and intent"]. Patient is currently assessed to be at [select value="no|low|moderate|high"] risk for self-injurious harm as evidenced by patient's self-report of [select value="not having any|having a"] self-injurious ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of patient having a suicidal ideation/plan/intent:[textarea cols="20" rows="1" default= "No action taken."]

3. Elopement Risk
[textarea default="Elopement mitigated by inpatient care at medium security psychiatric hospital"]

RISK ASSESSMENT

[text memo="Patient name"] has several static risk factors that raise their baseline risk for harm to self and others and inability to care for self. These include [text memo="SADPERSONS"]. 

Mitigating factors include [text]. Patient strengths include [text].

Convincingly contracted for safety. Patient is at [select value="Low|Moderate|High"] risk for harm to self-including deliberate self-harm, [select value="Low|Moderate|High"] risk for harm to others including intentional violence, Click or tap here to enter text. risk for vulnerability to harm, and [select value="Low|Moderate|High"] risk for inability to care for self in the context of standard inpatient psychiatric hospital setting.


FORMULATION/RATIONALE FOR DIAGNOSIS
[textarea memo="narrative about diagnosis and supporting elements. Plan."]