|
Telemedicine Consent
|
|
|
Procedure
• • •
|
Procedure Comments
|
|
Presenting Concerns
|
|
|
Past Medical History
|
|
|
Social History
|
|
|
Suicidal/Homicidal Ideation
|
Have you ever tried to harm or kill yourself?
|
|
Was your intent to die?
|
Action Taken?
|
|
Suicidal Ideation Frequency
|
How many times in your life has this occurred?
• • •
|
|
Intent/Plan Verbal Contract
|
Intent/Plan Comments
|
|
Mental Status
|
|
|
Appearance
|
Appearance Comments
|
|
Behavior
• • •
|
Behavior Comments
|
|
Speech
• • •
|
Speech Comments
|
|
Language
|
Language Comments
|
|
Knowledge
|
Knowledge Comments
|
|
Judgement
|
Judgement Comments
|
|
Orientation
|
Orientation Comments
|
|
Mood
• • •
|
Mood Comments
|
|
Affect
• • •
|
Affect Comments
|
|
Attn/Conc
|
Attn/Conc Comments
|
|
Memory
|
Memory Comments
|
|
Thought Process
• • •
|
Thought Processes Comments
|
|
Thought Content
• • •
|
Thought Content Comments
|
|
Intervention(s) Used
• • •
|
|
|
Clinical Impressions
|
|
|
Plan
|
|
|
Follow-Up
• • •
|
Follow Up Appointment Date/Comments
|
|
No Follow-Up Scheduled
• • •
|
No Follow-Up Scheduled Comments
|
|
Time Spent
|
|
