soap MH note

SUBJECTIVE REPORT

[textarea cols=60 rows=20 default=""]

OBERVATIONS of CONCERN

Appearance: [checkbox value="no concerns|seems under-developed|overweight|underweight|inappropriately clothed|disheveled & dirty clothing|bizarre clothing|neglected grooming|tense posture|slumped posture|bizarre manerisms|slowed movement|repetitive movement|restless|agitated|tremors"]
Attention: [checkbox value="no concerns|seemed unaware|inattentive|distractible|hyper-vigilant|scattered concentration|preoccupied|confused|focused on irrelevancies|was not oriented X 4|poor memory|confabulated"]
Engagement: [checkbox value="no concerns|avoidant eye contact|fixed staring|glaring at author|tense facial expression|dependent and needy|dramatic and exaggerating concerns|passive and difficult to engage|uninterested|silly and joking around|resistant|critical and verbally combative|hostile and threatening|sarcastic and taunting|irritable|fatuous|flirtatious|demanding|threatening|suspicious and guarded|defensive and resistant|manipulative|argumentative"]
Affect: [checkbox value="no concerns|labile affect|restricted affect|blunted affect|flat affect|anxious mood|angry mood|apathetic mood|ashamed mood|prideful mood|sad mood|irritable mood|hostile mood|pessimistic mood|depressed mood|hypomanic mood|euphoric mood"]
Speech and thoughts: [checkbox value="no concerns|was selectively mute|was completely mute|loud|laconic|quiet and difficult to hear|pressured|rambling|babbling|incongruent with mood and current circumstances|tending to take everything personally|assuming persecution by everyone|wrought with indecision and ambivalence|focused on the suspicious motives of others (persecutory thinking)|deluded and unrealistic |impaired by difficulties of reference|assuming magical ideas of influence and control|distorted by hallucinations|revealing a tendency towards pseudologica fantastica|tended to provide too much unnecessary detail (circumstantial)|wandered between too many topics (tangential thinking)|jumped from one idea to another (loose associations)|seemed to have racing thoughts (flight of ideas)|abruptly changed topic or stopped mid-sentence (thought blocking)|tended to loop or repeat themes (obsessive)|seemed stuck on over-valued ideas (preoccupations)"]
Orientation: [checkbox value="no concerns|AH|VH|poor judgement|distorted reality testing|poor insight|complete denial"]
Stressors disclosed without prompting: [checkbox value="nil|money|education|housing|employment|mood|family|work|grief and loss|illness|transitions|legal difficulties|peer group|relationship"]
Suicide risk: [select value="denied active suicidal ideation when asked|vague suicidal ideation|intense suicidal ideation|has a suicide plan without strong intent|has strong intent to suicide without a plan|has strong intent and a plan to complete suicide"].

ASSESSMENT

Risk assessment: [checkbox name="variable_30" value="I saw no need for further action today|I reminded the patient of their calling MHAL 1800011511 if needed, and urged them to present to the ED or call 000 in a crisis|Pt and I agreed to a harm minimization approach by removing access to lethal means|and I further discussed their risks with their parent|I called emergency services and reported my concerns|I called the MHAL and reported my concerns|I made a notification of suspected abuse to FACS"]
Diagnostic features: [checkbox name="variable_48" value="Developmental Disorder|Schizophrenia Spectrum Disorder|Bipolar Disorder|Depressive Disorder|Anxiety Disorder|OCD|Trauma, Stress and Adjustment related Disorders|Dissociative Disorder|Somatic Symptom related|Feeding and Eating related|Elimination related|Sleep-Wake Disorder|Sexual Dysfunction|Gender Dysphoria|Impulse Control related disorder|Substance related disorder|Neurocognitive Disorder|Personality disorder"], [checkbox name="variable_49" value="but would not meet criteria for a diagnosis at this time|and meets criteria for a clinical diagnosis"].
Pathogenic beliefs: [checkbox value="Nothing of note|ABANDONMENT - significant others are unstable, unreliable or unpredictable.|MISTRUST - others will intentionally hurt, abuse, cheat, or take advantage.|DEPRIVED - the desire emotional support is never adequately met by others.|DEFECTIVENESS - one is inherently flawed, defective, and unlovable.|ALIENATION - one is fundamentally different from other people and isolated|INCOMPETENCE - one is dependent of others to handle everyday life.|VULNERABILITY - an imminent and unpreventable catastrophe will strike at any time.|ENMESHMENT - emotional involvement with others is preferred over individuation.|INADEQUACY - failing to achieve and inadequate relative to one's peers.|SUPERIORITY - one is superior and entitled to special rights and privileges.|SELF-CONTROL - unable or unwilling to tolerate frustration to achieve one’s goals.|SUBJUGATION - one must surrender control to others and suppress one’s own needs.|SELF-SACRIFICE - must meet the needs of others at the expense of one’s own needs and 
well-being.|APPROVAL-SEEKING - needs to constantly seek-approval with an excessive emphasis on gaining approval, recognition, or attention from other people.|NEGATIVITY - Feels chronically pessimistic, which creates a pervasive, focus on the negative aspects of life.|INHIBITION - one must inhibit spontaneous feelings and actions.|HIGH STANDARDS - one must strive to meet high internalized standards.|PUNITIVE - people should be harshly punished for making mistakes."]
Overall functioning rated out of 100: [checkbox name="variable_43" value="91 – 100 No symptoms. Superior functioning in a wide range of activities|81 – 90 Absent or minimal symptoms, good functioning in all areas|71 – 80 If symptoms are present, they are transient and expected reactions to psychosocial stressors.|61 – 70 Some mild symptoms, but generally functioning pretty well.|51 – 60 Moderate difficulty in everyday functioning.|41 – 50 Serious impairment in everyday functioning.|31 – 40 Some impairment in reality testing or communication and major impairment in several areas.|21 – 30 Behaviour is considerably influenced by poor reality testing; an inability to function in almost all areas of life.|11 – 20 Some danger of hurting self or others; occasionally fails to maintain minimal personal hygiene; gross impairment in communication.|1 – 10 Persistent danger of severely hurting self or others; persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death.|0 Unable to rate"].
Maladaptive coping: [checkbox name="variable_55" value="Nothing of note|restrict calories|becomes over-assertive|feels the need to over-perform|avoids the situation|negatively ruminates|mentally replays unpleasant events|over-exercises|immerse in fantasy|negative self-talk|actively deny the problem|become increasingly passive and helpless|renounce all self-responsibility and blame others|focus completely on external factors|shut down all emotions|daydream|act out with defiance|yell and scream|threaten suicide|self-blame|act with passive-aggression|withdraw and become quiet|blame and justify|play the victim|act in a variety of compulsive ways|frantically seek reassurance|procrastinate|over-eat|binge eat|shoplift|overspend|act promiscuously|abuse substances|abuse alcohol|self-harm"]
Cognitive distortions: [checkbox name="variable_51" value="Nothing of note|filtering (selective attending)|polarization (splitting / all-or-nothing / black-and-white thinking)|over-generalization (concluding from one example)|discounting the positive (devaluing positive events)|jumping to conclusions (assuming things without evidence)|catastrophizing (always expecting the worst)|personalization (taking everything personally)|control fallacies (assuming one exerts too much or too little control)|fallacy of fairness (assuming the world should be fair)|blaming (others are responsible for how one feels)|shoulds (ironclad rules applied to oneself or others)|emotional reasoning (assuming the way one feels makes it a fact)|fallacy of change (expecting others to change if they would only apply more effort)|global labeling (using one concept to describe a complex system)|always being right (viewing ones opinions as facts)"].
Pathogenic personality features: [checkbox name="variable_52" value="Nothing of note|Paranoid (suspicious)|Schizoid (isolative)|Schizotypal (odd)|Antisocial (hostile)|Borderline (unstable)|Narcissistic (self-interested)|Avoidant (anxious)|Dependent (passive)|Obsessive-compulsive (controlling and rigid)"]
Progress: [checkbox name="variable_45 value="excellent|good|fair|poor|negligible"]

THERAPEUTIC APPROACH

Therapeutic Goals: [checkbox name="variable_44" value="enhancing mood|reducing and tolerating psychotic Sx|learning relaxation skills|learning mindfulness and meta-cognitive skills|developing greater insight|decreasing over-eating behaviours|increasing eating and calorie intake|decreasing ETOH misuse|enduring withdrawal of substances|enhancing distress tolerance skills|feeling more hopeful about the future|reducing symptom severity|improving sleep|enhancing a sense of self-efficacy|reducing physical pain|increasing psychological knowledge|becoming more assertive|adhering to recommended medical treatment|enhancing problem-solving skills|increasing resilience|modifying distorted cognitions and beliefs|becoming motivated to treat medical concerns|improving medication adherence and compliance|feeling enhanced self-agency|strengthening ego functioning"].
Therapy style: [checkbox name="variable_47" value="Cognitive Behavioural Therapy|Dialectical Behaviour Therapy|Behaviour Therapy|Relaxation Training|Mindfulness Training|Narrative Therapy|Family-based therapy|Group Therapy|Skills training|Psychoeducation|Insight oriented counselling|Emotional regulation skills training|Psychodynamic Counselling Techniques|enhance Psychosocial supports"], [comment memo="add a specific technique, using the format provided"] [textarea name="variable_7" default="in particular, guided meditation."][select value="Engaged well.|Struggled to engage.|Unable or unwilling to engage."]

PLAN

Focus of next session: [checkbox value="enhancing mood|reducing and tolerating psychotic Sx|learning relaxation skills|learning mindfulness and meta-cognitive skills|developing greater insight|decreasing over-eating behaviours|increasing eating and calorie intake|decreasing ETOH misuse|enduring withdrawal of substances|enhancing distress tolerance skills|feeling more hopeful about the future|reducing symptom severity|improving sleep|enhancing a sense of self-efficacy|reducing physical pain|increasing psychological knowledge|becoming more assertive|adhering to recommended medical treatment|enhancing problem-solving skills|increasing resilience|modifying distorted cognitions and beliefs|becoming motivated to treat medical concerns|improving medication adherence and compliance|feeling enhanced self-agency|strengthening ego functioning"]
Homework: [checkbox value="none|reflect on content of session|practice skills|notice patterns of dysfunction as they arise|keep a diary of emotions|keep a food diary of meals and feelings"].
Next apt: [textarea default="Wed / Thur"]