Star Progress Note w/ Initial & C-SSRS

[checkbox name="init" memo="Initial Session" value=""][select name="virt" memo="Session" value="in-person|phone|telehealth"][select name="sessiontype" value="youth for individual|family for family|PCG for individual caregiver|youth and sibling(s) for family"]session [select name="colum" memo="C-SSRS" value="no|none|low|moderate|high"]
[conditional field="virt" condition="(virt).is('phone')||(virt).is('telehealth')"]Counselor met with for a [var name="virt"] [conditional field="init" condition="(init).is('')"]initial [select name="inittype" value="consultation|intake"][/conditional] appointment. Counselor confirmed location as [text name="virtloc" default="Waco, Texas, at home"].  Counselor confirmed own identity and location. [/conditional][conditional field="init" condition="(init).is('')"]Counselor met with family for the initial [select name="inittype" value="consultation|intake"]  appointment. Family completed all required paperwork and discussed confidentiality. Counselor discussed and explained client rights, service limitations, professional credentials, supervision, and paperwork requirements. Family discussed the reasons they sought services and the presenting problem being [textarea name="presprob" default="struggles with emotional regulation/sh/si/anxiety/angry outburts\ncoping skills, overall family functioning etc."]
Counselor and family discussed strategies they can begin trying to help youth get on the right track.[/conditional]
[conditional field="init" condition="(init).isNot('')"][comment memo="Invervention"]Counselor met with [var name="sessiontype"] session. Today’s appointment focused on [textarea name="sessionfocus" default="focus here"][/conditional]
[remark]C-SSRS[/remark][conditional field="colum" condition="(colum).isNot('no')"] Assessed client using the C-SSRS.[/conditional][conditional field="colum" condition="(colum).is('none')"] Youth did not meet criteria.[/conditional][conditional field="colum" condition="(colum).is('low')||(colum).is('moderate')||(colum).is('high')"]Youth met criteria for [var name="colum"] risk ([select name="intent" value="without|with"] intent, [select name="plan" value="without|with"] plan).[/conditional][conditional field="colum" condition="(colum).is('high')"][comment memo_color="red" memo="Here is information specific to protocol with high risk."]Counselor discussed results with PCG directly and the need for youth to [textarea name="variable_1" default="receive psychiatric evaluation at the nearest hospital\nCall MCOT/MOT for psychiatric evaluation."]Counselor discussed results with PCG directly. A safety plan was constructed, including removing access to means and  PCG's responsibilities for youth's safety. Appropriate hospital/MCOT/MOT information was provided. Counselor spoke with PCG about attaining an ROI for [text name="variable_1" default="hospital/MCOT/MOT"] and a follow up [text name="variable_1" default="today/the next day"] to confirm youth received discussed services and discuss outcome of the evaluation. Based upon the evaluation outcome, counselor discussed offering next appointment as needed.[/conditional][conditional field="colum" condition="(colum).is('moderate')"][comment memo_color="orange" memo="Here is information specific to protocol with moderate risk."]Counselor discussed results with PCG directly. A safety plan was constructed, including removing access to means and  PCG's responsibilities for youth's safety. Appropriate hospital/MCOT/MOT information was provided. Next appointment is scheduled within 3 days.[/conditional][conditional field="colum" condition="(colum).is('low')"][comment memo_color="yellow" memo="Here is information specific to low risk."]Counselor discussed results with PCG directly. A safety plan was constructed, including removing access to means and  PCG's responsibilities for youth's safety. Appropriate hospital/MCOT/MOT information was provided.Next appointment is scheduled within 10 days.[/conditional]
[comment memo="Affect"][select name="yf" value="Youth|Family|PCG"] appeared [select name="affect" value="engaged|content|depressed|anxious|withdrawn|agitated"] during session, as evidenced by [checkbox name="obj" value="self-report|incoherent speech|hesitant speech|warm tone|flat tone|jittery movements|relaxed dialogue|eye contact|lack of eye contact|minimal participation in discussion|maximal participation in discussion|slumped posture|relaxed posture"].
[comment memo="Action Plan:"][conditional field="init" condition="(init).isNot('')"]Action Plan: [select name="approg1" value="Family|Youth|PCG"] discussed progress towards goals set on action plan and reported goals [select name="approg2" value=" are still appropriate and progress is being made|have been met and family will update action plan at next session|have been met and family updated action plan today"].[/conditional][conditional field="init" condition="(init).is('')"][comment memo="Initial Session"]Action Plan: Counselor reviewed PFS with family and developed initial goals and tasks for the action plan. Action plan was completed and [select name="APsent" value="signed and a copy was given to the family|sent to the family via EHR portal for signatures"]. [/conditional]
[textarea memo="Additional information" rows="1"]