Identifying Information: [text memo="Patient name" size="20"] is a [text memo="age" size="2"]-year-old, [text memo="ethnicity" size="20"], [checkbox value="female|male|transgender female|transgender male|gender non-binary individual"] who [checkbox value="lives alone|is homeless|lives with significant other|lives with parents|lives with a roommate"] in [text memo="residing location" size="20"]. Course of Treatment: [checkbox value="The patient was exposed to individual, group, and milieu based therapies"][checkbox value=" in addition to medication management"]. [textarea memo="additional info" rows="3"] Progress/Response to treatment: [checkbox value="Medications trialed this admission include: "][textarea memo="medication trials and result" rows="5"] [textarea memo="Description of improvement throughout treatment course during residential treatment" rows="5" text default="Relevant changes in psychiatric state include improved mood, decreased anxiety, and a commitment to continued abstinence from mind altering substances. The resident was a full and active participant in all aspects of their treatment plan and is actively embracing a robust aftercare plan including individual counseling and psychiatric care, Connect365, and they endorsed a commitment to active mutual aid society (e.g. AA, NA, etc.) participation and verbalized a commitment to reconnecting with their sponsor. At their discharge visit their mood was euthymic with a congruent affect. They describe their time at Sierra Tucson as productive and life changing and had a good deal of optimism regarding their future. They endorsed today that their current medication regimen for anxiety is working well for him and they has 0/10 anxiety. Their speech was logical and goal directed. They denied any perceptual disturbances, paranoid thoughts, or ideas of reference. Thought content was linear and coherent. They were well groomed, neatly attired, and exhibited a normal gait. There was no abnormal psychomotor movement and they denied any cravings or withdrawals. Concentration ability was intact. Sensorium was intact by observation; no formal testing conducted. Insight and judgment considered to be good. They adamantly denied any thoughts of self-harm, suicide, or any thoughts of wanting to harm others. They spoke very positively about their future as they prepares to transition to a life in recovery." ] [checkbox value="The patient adamantly denied any suicidal or homicidal ideation, and reported that they felt ready for next level of care. "][checkbox value="There were no further concerns expressed by social contacts or by members of the treatment team. "][textarea memo="additional disposition info" rows="5"] Psychiatric Risk Assessments: The patient is at a [select value="low|moderate|high"] acute and [select value="low|moderate|high"] chronic risk of suicide based on [checkbox value="lack of current suicidal ideation|current suicidal ideation|intent"] and [select value="well|moderately|poorly"] treated psychiatric symptoms at this time. The patient has [checkbox value="no history of suicide attempts|a history of suicide attempts|a recent history of suicidal ideation|difficulty with supportive relationships|a minimal support system outside the hospital"]. They present as [checkbox value="future oriented|with plans for self-improvement|having a strong sense of personal responsibility|ambivalent about personal outcomes|pessimistic about personal outcomes"]. [textarea memo="additional information about suicide risk factors" rows="3"] The patient is at a [select value="low|moderate|high"] acute and [select value="low|moderate|high"] chronic risk of violence based on [checkbox value="lack of current violent ideation|current violent ideation|intent"] and [select value="well|moderately|poorly"] treated psychiatric symptoms at this time. The patient had [checkbox value="a lack of violent behaviors on the unit|agitated behaviors on the unit|agitated and violent behaviors on the unit|displayed adequate mood regulation|displayed difficulty with mood regulation"]. Prior to admission the patient had [checkbox value="no history of agitation and violence|a recent history of agitation and violence|difficulty with mood regulation|but has improved significantly with treatment|has made moderate improvement with treatment|has made minimal improvement with treatment|has made no improvement with treatment"]. [textarea memo="additional information about violence risk factors" rows="3"] Additional Medical Issues Addressed During Residential treatment: [checkbox value="There were no acute medical issues addressed during residential treatment. "][checkbox value="There were no abnormal laboratory values noted. |Notable abnormal laboratory values this admission include: "][textarea memo="abnormal laboratory information if applicable" rows="3"][checkbox value=" which resolved without intervention. "][textarea memo="additional information about medical issues and interventions" rows="3"] Prognosis: Prognosis is [select value="good|fair|poor"] considering the patient remains adherent to medication and therapy to address [textarea memo="target of treatment" rows="1"][checkbox value=" and whether they are able to engage constructively with social supports"]. [checkbox value="Barriers to success outside of residential treatment include: "][textarea memo="barriers" rows="3"] [checkbox value="Patient strength for success outside of residential treatment include: "][checkbox value="were willing and able to seek treatment|have positive social supports|are well connected with outpatient supports|have a history of actively engaging in outpatient treatment"][textarea memo="strengths" rows="3"]
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