Psychiatry OPD follow up

Patient was seen    for    a    follow    up    appointment    via   [select name="variable_1" value="zoom|phone|in-person"]    
[textarea name="variable_1" default="During encounter patient was calm and  cooperative, as per patient things have been    pretty stable.Patient denied any acute    concerns related to depression,anxiety or  psychosis.Patient has been compliant with    their medications and denied any side effects    from the medications."]  

MSE:    
Appearence:[select name="variable_2" value="limited due to nature of the encounter|well   kempt, good personal hygiene|poor personal    hygiene"]
Eye contact: good
behaviour : calm and cooperative    
Mood:[textarea name="variable_3" default=""]
Affect: [textarea name="variable_4" default=""]
TP: logical and linear    
TC: denied SHIIP
Perceptions:denied AVH    
insight: good    
judgement : good    

Istop:
Comments:[textarea name="variable_5" default=""]

Substance Use:
Primary substance :[textarea name="variable_6" default=""] 
Last Use: [textarea name="variable_7" default=""]  
Other substance use:  
Patient [select name="variable_3" value="endorsed|denied"] using any other    substances[textarea name="variable_8" default=""]

Suicide Risk Report 
Date: [date name="variable_1" default="timestamp"]

-- SUICIDE RISK SUMMARY -- 

Pt reported they are [checkbox value="not|actively|passively"] suicidal, with [checkbox value="no|firm|vague|lethal|nonlethal|undisclosed"] plans to end their life. The patient verbally confirmed they [checkbox value="have no intention to suicide|intend to die|have ambivalent feelings about suicide"].

-- PATIENT REPORT --

The patient reported they [select value="do not feel|feel"] like giving up on life. Their future seems [select name="variable_1" value="hopeful|hopeless"] and their life [select name="variable_2" value="does not seem|seems"] so bad that they wish to die. They further reported [checkbox name="freq" value="no suicidal thoughts.|having suicidal thoughts"][conditional field="freq" condition="(freq).is('having suicidal thoughts')"] [checkbox value="infrequently|most days|every day"], and rated these thoughts as [checkbox value="mild|moderate|severe"] in their intensity. When asked about having suicidal plans, the patient reported [checkbox value="no plans|vague ideas about it|having a definite plan|they are unwilling to discuss it"]. When further asked about how close have they been to acting on these thoughts in the past, the patient reported [checkbox value="not close at all|very close|they did indeed attempt suicide|they do not wish to discuss it"]. When asked how certain they feel about acting on these thoughts in the future, the patient reported [checkbox value="it's unlikely|they weren't sure|they were absolutely certain|they did not wish to discuss it"] Finally, when I asked about having access to the means to suicide, the patient reported [checkbox value="no|yes possibly|yes absolutely"][/conditional]

[checkbox name="prosu" value="-- PROTECTIVE FACTORS --"][conditional field="prosu" condition="(prosu).is('-- PROTECTIVE FACTORS --')"] 

[checkbox value="treatment responsiveness|connectedness to individuals, family, community, and social institutions|problem-solving skills|coping skills|ability to adapt to change|they sense of purpose or meaning in life Cultural, religious, or 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|they strong sense of self-worth or self-esteem|a sense of personal control or determination|access to a variety of clinical interventions and support for seeking help|resiliency|expressed reasons for living|being married|being a parent|strong relationships, particularly with family members|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"][/conditional]

[checkbox name="stat" value="-- STATIC RISK FACTORS --"][conditional field="stat" condition="(stat).is('-- STATIC RISK FACTORS --')"] 

[checkbox value="Hx of denying the need for service contact|Hx of avoiding of service contact|non-responsiveness to pharmacological treatment|non-responsiveness to psycho-social interventions|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|Hx of substance abuse|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 behavior|Hx of reckless and self-endangering behaviors|Absolutistic thinking|Tunnel vision|Limited capacity for
self-­-soothing|Perfectionism|sexual orientation rejected by family|Guns
in the home|access to abundant medications|chronic medical illness|chronic pain"][/conditional]

[checkbox name="acute" value="-- ACUTE RISK FACTORS --"][conditional field="acute" condition="(acute).is('-- ACUTE RISK FACTORS --')"] 

[checkbox value="current suicidal ideation|current suicidal plan|plan lethality|preparation behahiours|vocalising threat to suicide|rehearsal behaviours|recent suicide attempt|regrets not dying|acute mood disorder|current substance abuse|increased substance abuse|mood lability|suicide command hallucinations|insomnia|persistent nightmares|unremitting pain|persistent distress|persistent agitation|tearful|guarded|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 MHIPU|loss of job|financial pressure|loss of status|suicide of close friend|declining health|pending legal issues|pending criminal charges|being victimised"][/conditional]

[checkbox name="Dyna" value="-- DYNAMIC RISK FACTORS --"][conditional field="Dyna" condition="(Dyna).is('-- DYNAMIC RISK FACTORS --')"] 

[checkbox value="untreated mental illness|suicidal thinking|homelessness|personality disorder|lack of distress tolerance skills|lack of therapeutic alliance|has access to lethal means|withdrawal from support groups|treatment compliance|abuse of substances|psycho-social stressors|problem-solving|feelings of hopelessness|feelings of anger|lack of professional skills|unmet needs"][/conditional].

- RISK MANAGEMENT RECOMMENDATIONS for PATIENT-- 

[checkbox value="hospitalization for imminent risk for suicide|immediate assessment with MH professional|remove lethal means|monitoring by family / friends|inform family of risk|recommended treatment of MH Sx|recommend D&A treatment service|help Pt improving their coping strategies|challenging negative beliefs|emphasize behavioral control|behavioural activation|increase pleasant activities|provide suicide crisis plan: call XXX or present to ED after hours|call Crisis Team after hours contact number or CMH number to call during business hours|PRN medications|alert supportive individuals|increase psychosocial supports|Encourage reality-testing with family, friends or professionals|provide thought interruption strategies|after-hours numbers to call|Written safety plan"]
Patient was seen for a follow up appointment via


MSE:
Appearence:
Eye contact: good
behaviour : calm and cooperative
Mood:

Affect:

TP: logical and linear
TC: denied SHIIP
Perceptions:denied AVH
insight: good
judgement : good

Istop:
Comments:


Substance Use:
Primary substance :

Last Use:

Other substance use:
Patient using any other substances


Suicide Risk Report
Date:

-- SUICIDE RISK SUMMARY --

Pt reported they are suicidal, with plans to end their life. The patient verbally confirmed they .

-- PATIENT REPORT --

The patient reported they like giving up on life. Their future seems and their life so bad that they wish to die. They further reported







.

- RISK MANAGEMENT RECOMMENDATIONS for PATIENT--

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.79, 38 form elements, 110 boilerplate words, 7 text areas, 1 dates, 19 checkboxes, 6 drop downs, 5 conditionals, 198 total clicks
Questions/General site feedback · Help Ticket

2 responses to “Psychiatry OPD follow up”

  1. Anna Philipose says:

    I liked this. I work in an FQHC to do psychiatric consults as a Team Provider working with Primary Care Providers and Behavioral Health Consultants. I wonder if I can incorporate this into my favorite to use as a template in the EHR. If you have any specific suggestions, I would appreciate it. Thank you.

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