[Main Page of Report | Contents of Report]
| Categorical | Narrative | Both | |
|---|---|---|---|
| Demographic/administrative information | |||
| Patient’s Name | 11 | ||
| Patient’s Date of Birth | 10 | ||
| Patient’s SSN | 10 | ||
| Patient’s Age | 2 | ||
| Patient’s Gender | 2 | ||
| Marital Status | 1 | ||
| # Dependents | 1 | ||
| Occupation | 2 | ||
| Primary Language | 1 | ||
| Living Arrangements | 1 | ||
| CYFD Custody (Y/N), Social Worker Name and Phone | 1 | ||
| JPPO/APPO (Y/N), Probation Officer Name and Phone | 1 | ||
| Guardian Name and Phone (Minor) | 1 | ||
| Waiver Status (Enrolled/Waiting List), and Waiver Type | 1 | ||
| Patient on Long or Short Term Disability | 2 | ||
| Patient Receiving Worker’s Compensation | 1 | ||
| Insured’s Name, Address, SSN, Employer | 2 | ||
| Patient’s Relationship to Insured | 2 | ||
| Initial Authorization or Continuing | 6 | 1 | |
| Treatment Start/End Dates | 8 | ||
| Treatment Court Ordered? | 1 | ||
| Practitioner’s Name, Address, Phone | 11 | ||
| Practitioner’s ID number and/or License Number | 10 | ||
| Patient History | |||
| Previous MH/SA Treatment? With Same Provider? | 2 | 4 | 2 |
| Overall efficacy of treatment to date | 3 | 1 | |
| History of Substance Abuse | 2 | 5 | 1 |
| Medical History | 3 | ||
| Allergies | 1 | ||
| Diagnosis | |||
| DSM-IV Diagnosis | 11 | ||
| Global Assessment of Functioning (GAF) | 10 | ||
| Highest GAF in Past Year | 8 | ||
| Lowest GAF in Past Year | 1 | ||
| Expected GAF at Discharge | 1 | ||
| Any Change in Initial Diagnosis | 2 | ||
| Current/Presenting Problems | |||
| Symptoms | |||
| Socially isolated | 1 | ||
| Unstable/intense relationships | 2 | ||
| Perfectionist/controlling/rigid | 1 | ||
| Distrustful/suspicious | 1 | ||
| Nonconforming to laws/norms | 1 | ||
| Threatening | 1 | ||
| Assaultive | 1 | ||
| Tantrums | 1 | ||
| Self-mutilating | 2 | 1 | |
| Implusive | 3 | 1 | |
| Oppositional/defiant | 3 | 1 | |
| Work/school inhibition | 1 | ||
| Agitation | 1 | ||
| Motor retardation | 1 | ||
| Hyperactive | 3 | ||
| Mania | 1 | ||
| Disorganized | 1 | ||
| Impaired attention/concentration | 3 | 1 | |
| Memory impairment | 3 | ||
| Concrete Thinking | 1 | ||
| Disorientation to time, place, person or situation | 1 | 1 | |
| Impaired judgment | 3 | 1 | |
| Lack of insight | 1 | 1 | |
| Circumstantiality/tangentiality | 1 | ||
| Flight of ideas/racing thoughts | 1 | 2 | |
| Distorted idiosyncratic thinking | 2 | ||
| Depressed mood | 4 | 1 | |
| Decreased energy | 1 | 1 | |
| Withdrawn behavior | 1 | ||
| Dysphoric | 1 | ||
| Apathetic | 1 | ||
| Euthymic | 1 | ||
| Hostile | 1 | ||
| Fearful | 1 | ||
| Restricted | 1 | ||
| Tearfulness | 2 | ||
| Grief | 1 | ||
| Elated mood | 3 | ||
| Labile mood | 1 | 2 | |
| Low self-esteem/excessive | 1 | ||
| Hopelessness/Helplessness | 2 | 1 | |
| Worthlessness | 1 | 2 | |
| Guilt | 1 | 1 | |
| Irritability/Inappropriate anger | 3 | 2 | |
| Loss of interest/anhedonia | 2 | ||
| Pain | 1 | 1 | |
| Avoidant behavior | 1 | ||
| Phobia | 3 | 1 | |
| Obsessions/compulsions | 4 | 2 | |
| Panic attacks | 4 | 1 | |
| Somatization | 4 | 1 | |
| Generalized anxiety | 4 | 1 | |
| Separation anxiety | 1 | ||
| Hallucinations | 3 | 2 | |
| Delusions | 3 | 2 | |
| Paranoia | 3 | 1 | |
| Ideas of reference | 1 | ||
| Flashbacks | 1 | ||
| Depersonalization/dissociation | 2 | 1 | |
| Concomitant Medical Condition | 1 | 1 | |
| Emotional/Physical/Sexual trauma victim | 2 | 1 | |
| Emotional/Physical/Sexual trauma perpetrator | 1 | ||
| Appetite disturbance | 2 | ||
| Bizarre behavior | 1 | 1 | |
| Conduct problems | 1 | ||
| Gender issues | 1 | ||
| Bizarre ideation | 1 | ||
| Independent living problems | 1 | ||
| Poor self-care skills | 1 | 1 | |
| Dementia | 1 | ||
| ADHD | 1 | ||
| Speech – slow, pressured, monotone, soft, loud, normal | 1 | ||
| Appearance – unkempt, disheveled, unclean, appropriate | 1 | ||
| Substance abuse | |||
| Current Substance Abuse | 5 | 1 | 3 |
| Type of Substance Being Used | 1 | 2 | |
| Continued substance use in spite of knowledge of effects | 1 | ||
| Mood swings | 2 | ||
| Inability to control/decrease substance use | 2 | ||
| Persistent desire for substance/preoccupation | 2 | ||
| Daily use/morning use/solitary use/secretive use | 1 | ||
| IV use | 1 | ||
| Medicinal use | 1 | ||
| Rapid intake | 1 | ||
| Excessive consumption/binge | 1 | ||
| Tolerance of substance | 2 | ||
| Protecting supply | 1 | ||
| Passing out/blackouts | 1 | ||
| Withdrawal | 2 | ||
| Family history of addiction | 1 | 2 | 1 |
| Duration and Severity of Symptoms | 6 | 1 | |
| Risk Assessment | |||
| Suicide/Homicide | 5 | 3 | |
| Family Violence | 1 | ||
| Self-Injury | 1 | 2 | |
| Fire Setting | 1 | ||
| High Impulsivity/Aggression | 1 | ||
| Psychosis | 1 | ||
| Non-Compliance with Treatment | 1 | ||
| Lack of Social Support | 1 | ||
| Other Risk Behaviors | 2 | 1 | |
| Psychological Testing | 1 | ||
| Risk of Relapse | 1 | ||
| Level of Functioning | |||
| Relationships – Marriage, Family, Friends | 4 | 2 | 2 |
| Job/School Performance | 4 | 2 | 2 |
| Hobbies/Interests/Activities | 1 | ||
| Physical Health | 4 | 1 | |
| Financial | 3 | ||
| Activities of Daily Living | 2 | ||
| Eating Habits | 2 | 1 | |
| Weight Loss/Gain and Current Weight | 1 | 1 | 1 |
| Sleeping Habits | 4 | 1 | |
| Sexual Functioning | 4 | 1 | |
| Legal Problems | 2 | 1 | |
| Psychiatric/Emotional Problems | 1 | 1 | |
| Behavioral Problems | 1 | 1 | |
| Cognitive Impairment | 1 | 1 | |
| Treatment Information | |||
| Requested Procedures/Types of Services | 8 | 1 | 2 |
| Dates of Treatment, Frequency and Duration | 4 | 7 | |
| Location of Treatment (Office, Clinic, School, Home) | 1 | ||
| Treatment Approach | 1 | ||
| Expected Treatment Outcomes/Goals | 4 | 5 | |
| Member Notified/Concurs With Goals? | 5 | 1 | |
| Progress in Treatment | 2 | 3 | |
| Obstacles to Progress | 1 | ||
| Current Medications | 2 | 8 | |
| Medication Dosage/Frequency | 1 | 7 | |
| Side Effects | 3 | 1 | |
| Prescribing Clinician’s Name | 3 | ||
| Medication Start Date | 1 | ||
| Current Medication Compliance | 3 | 3 | |
| Medication Results in Improvement | 1 | ||
| Communication with PCP | 6 | 1 | |
| Family/Guardian Involvement and Progress in Treatment | 1 | 2 | |
| Other Family Members in Treatment | 1 | 1 | |
| Patient Receiving Other Treatment or Community Services | 4 | 3 | 2 |
| Discharge Criteria | 2 | ||
| Barriers to Discharge (Including Plans to Address) | 2 | ||
| Living Situation After Discharge | 1 | ||
| Aftercare Plan | 1 | ||
| Support Group | 1 | ||