Mental Health Progress

#Mental Health Progress

S: Subjective

Current Symptoms: 
(-) Low/depressed mood 
(-) Anxiety 
(-) Mood swings 
(-) Reduced ability to cope with daily problems or stress 
(-) Lowered energy or motivation 
(-) Elevated energy/arousal 
(-) Initial insomnia 
(-) Early morning wakening 
(-) Daytime sleepiness 
(-) Excessive fears or worries, or extreme feelings of guilt 
(-) Confused thinking or reduced ability to concentrate 
(-) Detachment from reality (delusions), paranoia or hallucinations 
(-) Trouble understanding and relating to situations and to people 
(-) Changes in eating habits or appetite 
(-) Weight loss/gain 
(-) Libido changes 
(-) Excessive anger, hostility or violence 
(-) Other -> 
Comments:

Progress Since Last Review: 
1. Things that are better:

2. Things that are worse:

3. Things that have not changed:

4. New problems or concerns:

Patient Feedback on Therapy Sessions (if applicable): 
1. Sessions Completed Since Last Review: ?

2. Patient comments:

Communication Received From Therapy Provider/s:

Current Psychotropic Medication Review: 
- Agent: 
- Date started: 
- Effectiveness: 
- Side effects:

- Agent: 
- Date started: 
- Effectiveness: 
- Side effects:

O: Objective

Mental State Observations: **abnormalities**
(-) Appearance
(-) Behaviour
(-) Motor activity
(-) Speech
(-) Mood (patient subjective)
(-) Affect (examiner observations)
(-) Thought processes
(-) Thought content
(-) Perceptions
(-) Cognition
(-) Orientation
(-) Attention/concentration
(-) Memory
(-) Abstract reasoning
(-) Insight
(-) Judgement
(-) Numeric skills
(-) Construction and spatial skills
(-) Abstract thinking
(-) Other comments ->

Mental Health Assessment Tool (K10/DASS21):

A: Assessment

Diagnosis / DDx:

Clinical Assessment of Progress Since Last Review:

Impairment (social, educational, employment):

Suicide/Self Harm: 
(-) ideation/thoughts, (-) intent/plan ->

Harm To Others: 
(-) ideation/thoughts, (-) intent/plan ->

P: Plan

Investigations:

Modification of Treatment Plan if Required:

Changes to Prescribed Medication:

Checking, Reinforcing and Expanding Education:

Actions to be Taken by Patient:

Role of Carer/Support Person(s):

Referrals:

Review:

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Mental Health Progress

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