|
RISK ASSESSMENT
|
|
|
LOW RISK
|
|
|
OTHER RISK
|
OTHER RISK LEVEL
|
|
OK FOR OUTPATIENT
|
|
|
SAFETY PLAN
|
Other:
|
|
PLAN
|
|
|
MEDICATION PLAN
|
|
|
PRESCRIBED MEDICATION(s) TODAY
|
|
|
NO MEDS PRESCRIBED TODAY
|
Other:
|
|
Rx TYPE
|
Other:
|
|
|
|
|
ADDITIONAL SERVICES RECOMMENDED
• • •
|
Other
|
|
LABS/ TESTS
• • •
|
Other:
|
|
F/U APPOINTMENT RECOMMENDED
|
|
|
NO FOLLOW UP RECOMMENDED
|
Other:
|
|
FOLLOW UP:
|
Other:
|
|
F/U APPOINTMENT LENGTH SUGGESTED
|
Other:
|
|
LOCATION SUGGESTED
|
Other
|
|
PSYCHOEDUCATION
|
|
|
Patient Psychoeducation
|
|
|
Patient and GUARDIAN psychoeducation
|
|
|
GUARDIAN PSYCHOEDUCATION
|
|
|
ANTIDEPRESSANT informed consent
|
PREGNANCY while on med risk
|
|
|
BREASTFEEDING
|
|
|
NUTRITIONAL EDUCATION
|
|
|
SLEEP HYGIENE
|
|
|
ENCOURAGED PHYSICAL EXERCISE
|
|
|
DISCUSSED ABSTAINING FROM ALCOHOL AND DRUGS
|
|
STIMULANT informed consent
|
|
|
NO CARDIAC RISK FACTORS
|
Other:
|
|
REFERRAL for cardiac clearance
|
|
|
|
BENZODIAZEPINE RISKS DISCUSSED
|
|
|
BENZO-OPIATE RISK
|
|
E-FORCSE (no inconsistencies)
|
|
|
E-FORCSE (data not found)
|
|
|
E-FORCSE (OTHER)
|
Other:
|
