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Assessment Type
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Chief Complaint
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Assessment type
• • •
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Patient states
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Today patient states there is
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Current stressors
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Medication Side Effects
• • •
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Explain "other" side effects
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Information provided by
• • •
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Behavior
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Stable and uneventful
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Medication compliance is good
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If no, Explain
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Eating well
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If no, Explain
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Sleeping well
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If no, Explain
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Caring for personal needs
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if no, Explain
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Taking care of responsibilities, i.e. housework, home, or school
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Explain
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ROS
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Pt has symptoms of/ problem pertinent ROS
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Abuse/assault
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Started when
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By whom
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Reported
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Lasting consequences
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ADHD
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Symptoms occur
• • •
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ADHD symptoms
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Fails to give close attention to detail
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Careless mistakes
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Difficulty sustaining attention in tasks
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Does not seem to listen when spoken to directly
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Does not follow through on instructions and fails to finish, loses focus easily
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Difficulty organizing tasks or activities, poor attention to detail
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Reluctant to engage in activities requiring sustained mental effort
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Often loses things
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Easily distracted by extraneous stimuli
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Forgetful in daily activities
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Fidgets and squirms in seat
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Leaves seat in situations where it is not appropriate to do so
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Runs about or climbs when it is not appropriate to do so
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Noisy
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Feels as if driven by a motor
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Talks excessively
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Blurts out answers
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Difficulty waiting turn
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Often interrupts
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ADJUSTMENT DISORDER
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Identifiable stressor
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Explain
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Marked distress out of proportion to severity or intensity of stressor
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Significant impairment in major life areas
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Explain
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Was stressor less than 6 months ago
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Explain
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Accompanying mood
• • •
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ANGER/AGGRESSION
• • •
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Explain
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ANXIETY IS PRESENT
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How often does anxiety occur
• • •
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Anxiety symptom severity/rating
/
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Anxiety symptoms severity/rating from last appointment
/
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Anxiety symptoms
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Excessive worry
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Difficult to control
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Restlessness or feeling keyed up or on edge
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Being easily fatigued
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Difficulty concentrating or mind going blank
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Muscle tension
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Sleep disturbance
• • •
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Anxiety symptoms related to substances
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Explain
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SOCIAL ANXIETY/SOCIAL PHOBIA PRESENT
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How often are symptoms experienced
• • •
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Social anxiety/phobia symptom rating/severity
/
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Social anxiety/phobia symptom rating/severity from last appointment
/
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Social anxiety/phobia symptoms
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Marked fear or anxiety about one or more social situations where scrutiny may be present
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Fear of negative evaluation is fear or anxiety shows
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Social situations almost always provoke fear or anxiety
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Social settings avoided or endured with intense fear
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Fear out of proportion to the actual threat
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Symptoms have persisted for at least 6 months
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Causes clinically persistent distress in major life areas
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Symptoms substance induced
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Explain
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PTSD PRESENT
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PTSD symptoms occur how frequently
• • •
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Trauma expereinced
• • •
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describe trauma
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PTSD symptoms severity/rating
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PTSD symptoms severity/rating from previous appointment
/
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PTSD symptoms
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Intrusive, distressing memories of traumatic event
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Recurrent, distressing dreams
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Flashbacks
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Intense and prolonged distress at reminders
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Inability to remember key aspects of trauma
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Somatic reactions to reminders
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Explain
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Avoidance of reminders/memories
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Avoidance of people, places, tings
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Persistent negative beliefs about self or the world
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Self-blame
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Diminished interest in once enjoyed activities
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Persistent negative emotional state
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Feelings of detachment or estrangement from others
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Inability to experience positive emotions
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Hypervigilance
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Irritability or anger
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Reckless, self-destructive behavior
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Explain
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Poor concentration
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Exaggerated startle response
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Sleep disturbance
• • •
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AUTISM SPECTRUM
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Chronic autism symptoms
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Severity
• • •
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Accompanied by
• • •
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Persistent deficits in social communication and interactions
• • •
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Restricted, repetitive patterns of behavior, interests, or activities
• • •
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Comments
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CHEMICAL DEPENDENCY
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Alcohol
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Describe
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Hallucinogens
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Describe
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Inhalants
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Describe
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Opioids
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Describe
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Sedative, hypnotic, anxiolytics
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Describe
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Stimulants
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Describe
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Tobacco
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Describe
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Marijuana
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Describe
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CONDUCT DISORDER (CURRENT OR BY HISTORY)
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Aggression to people and animals
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Often bullies, threatens, or intimidates others
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Often initiates physical fights
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Explain
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Has used a weapon that can cause serious physical harm
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Has been physically cruel to people
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Has been physically cruel to animals
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Has stolen while confronting a victim
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Explain
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Has forced some into sexual activity
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Destruction of property
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Has deliberately engaged in fire setting with intention of causing serious damage
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Deceitfulness or theft
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Has deliberately destroyed others’ property
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Has broken into someone else’s house, building, or car
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Often lies to obtain goods or favors or to avoid obligations
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Has shoplifted, forgery
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Childhood onset
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Adolescent onset
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DEPRESSION IS PRESENT
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How often does depression occur
• • •
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Depression symptom severity/rating
/
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Depression symptom severity/rating from previous appointment
/
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Depression symptoms
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Pt reports depressed mood most of the day nearly every day
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Pt reports marked diminished interest or pleasure in once enjoyed activities
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Significant weight changes and or appetite changes
• • •
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Pt report sleep disturbance every day or nearly every day
• • •
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Number of hours per sleep per night
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Pt reports fatigue or loss of energy nearly everyday
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Pt reports change in activity levels
• • •
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Pt reports of worthlessness or excessive/inappropriate guilt
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Pt reports poor concentration
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Depression symptoms related to substances
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Explain
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DEMENTIA/TBI/DELIRIUM
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Explain
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EATING DISORDER
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Anorexia
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Describe
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Bulemia
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Describe
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Binge-eating
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Describe
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GRIEF
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Grief explained
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MANIA
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Inflated self esteem or grandiosity
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Decreased need for sleep
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Describe
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More talkative than usual or pressured speech
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Flight of ideas or subjective experience that thoughts are racing
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Distractibility
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Increase in goal directed activity
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Excessive involvement in activities that have a high potential for painful consequence
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OCD
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Obsessions
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Recurrent, persistent, intrusive images
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Compulsions
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Repetitive behaviors aimed at preventing anxiety, distress, or preventing some dreaded event or situation
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OCD Described
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ODD (children)
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Angry/irritable mood
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Often loses temper
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Is often touchy or easily annoyed
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Is often angry and resentful
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Argumentative/defiant behavior
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Often argues with authority figures/adults
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Often actively defies or refuses to comply with requests from authority figures or rules
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Often deliberately annoys others
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Often blames others for mistakes or misbehavior
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Vindictiveness
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Has been spiteful or vindictive at least twice within the past 6 months
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PERSONALITY DISORDER
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Avoidant personality disorder
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Explain
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Borderline personality disorder
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Explain
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Paranoid personality disorder
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Explain
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Schizoid personality disorder
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Explain
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Schizotypal personality disorder
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Explain
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Antisocial personality disorder
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Explain
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Histrionic personality disorder
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Explain
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Narcissistic personality disorder
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Explain
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Avoidant personality disorder
|
Explain
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Dependent personality disorder
|
Explain
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Obsessive compulsive personality disorder
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Explain
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Pervasive Developmental Disorder
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Psychosis
• • •
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Reactive Attachment Disorder
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Review of systems
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ROS/constitutional WNL
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Any new or persistent physical complaints
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Have you spoken to your primary care provider about this
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Will you
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Comments
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New Patient info
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IDENTIFYING INFORMATION
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Marital Status
• • •
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Patient Sex
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Sexual Hx
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Comments
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Occupation
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How long at current job
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Previous job length of time
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New Short Text Field
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Living Arrangements
• • •
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Multiple job changes
• • •
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Explain frequent job changes
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Medical History
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Past Medical History
• • •
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Past Medical History Freewrite
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Past Surgical History
• • •
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Comments
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PCP
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PCP Contact Information
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Date of last PE
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Current medical condition being treated (both acute and chronic)
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CLIENT’S MENTAL HEALTH HISTORY
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Ever diagnosed with:
• • •
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Prior antidepressants
• • •
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Social History
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Client's Place of Birth
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Development
• • •
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Development Explain
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Client's Family Biological/Adopt
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Client Adopted Age
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Client's # of Moves in Lifetime
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explain moves
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Client's Parents Married
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Client Raised by (Parent)
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Client's # of Siblings(Name(s)/A
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place in family
/
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Describe family life
• • •
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Explain family life
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MILITARY SERVICE
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Military Service
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Military Service Branch
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Military Service Active Duty
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Military - Type of Discharge
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Military - Date of Discharge
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LEGAL HISTORY (Explain if Necess
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explain legal history
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Ever Arrested
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Ever Convicted
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Current Legal Problems
• • •
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Explain other:
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SPIRITUAL HISTORY
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Spiritual/Cultural Belief System
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Spiritual/Cultural Comments
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Mental Status Exam
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Observations
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Appearance
• • •
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Others, please specify
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Behavior
• • •
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Others, please specify
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Speech rate
• • •
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Others, please specify
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Speech Fluency
• • •
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fluency description
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speech spontaneity
• • •
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if not spontaneous, describe
• • •
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Speech volume
• • •
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Tone of speech
• • •
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Eye Contact
• • •
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Others, please specify
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Motor Activity
• • •
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Others, please specify
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Affect
• • •
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Others, please specify
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Mood
• • •
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Others, please specify
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Thought Content
• • •
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Delusions described
• • •
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Thought Processes
• • •
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New Short Text Field
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Cognition/dementia
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Thought processes described
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Orientation impairment
• • •
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Judgment
• • •
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Insight
• • •
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Memory impairment
• • •
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Others, please specify
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Comments
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Perception
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Hallucinations
• • •
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Others, please specify
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Other
• • •
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Comments
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Thoughts/Safety
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Suicidality
• • •
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Plan
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Explain
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Intent
|
Explain
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Self-harm
|
Explain
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Hospital referral needed for injuries
|
Explain
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Homicidality
• • •
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Intent
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Explain
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Plan
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Explain
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Internal coping strategies
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People and social settings that provide distraction
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People who I can ask for help
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Professionals or agencies I can contact during a crisis:
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Hospitals with psychiatric services
• • •
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Create a safe environment
• • •
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Others, please specify
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Comments
|
|
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Others, please specify
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Gait is normal and station is erect
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If no, explain
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Drug withdrawal or intoxication is currently present
|
If yes, explain
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IQ
• • •
|
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Instructions/recommendations/plans
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The following level of care is recommended
• • •
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Therapy modalities used today
• • •
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Referrals
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Medical
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Comments
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Neuropsychological
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Comments
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Counselor
|
Comments
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Medication Management
|
Medication Changes:
|
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New Medication Rationale
• • •
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Taper Medication Rationale
• • •
|
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Continue Medication Rationale
• • •
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Labs
• • •
|
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Current Medications
|
Medication notes
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Lithium Labs
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Labs for anticonvulsants
|
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Routine labs
|
Education
• • •
|
|
Therapy content/Clinical summary
|
|
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Today the patient focused on feelings of
• • •
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Focus of therapy today was
• • •
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Therapeutic efforts focused on
• • •
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The patient was counseled and educated on
• • •
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Interventions Introduced
• • •
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Response to Intervention
|
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Client homework
• • •
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Plan for next session
|
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Return appointment
• • •
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Release of information
|
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Medical Decision Making
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Low complexity
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Medium Complexiety
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High Complexiety
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