Tracy Costello of National Louis University has an important message to make it possible:
If you use "Reason for Referral", you pretty much have to copy whatever the consult says. Unfortunately, many consults ask questions which tests can't answer or else they don't ask any question at all. Use this section to briefly introduce the patient and the problem.
Begin with a concise "demographic picture" of the patient. She was admitted due to symptoms of major depression with possible psychotic features. Use this section to tell your reader what issues you will address in the body of the report.
In this way, he won't get to the end of your report, then have to think back to decide whether your conclusions were supported by your data.
He'll know on what issues to focus, and he can be forming his own impressions while he's reading. Finally, if the evaluation takes more than 5 days to complete, you should put a progress note in the patient's chart giving preliminary test results.
The current report will supplement and elaborate upon those preliminary findings. This also helps communicate to referral sources that you do more than give some tests and copy interpretive statements out of a manual. It lets them know that your evaluation is a professional integration of information from a variety of sources.
Be sure to also note who gave the tests and how long it took. These issues are important if a case ever goes to court.
Tests were administered by Jim Smith, M. In this section present paragraphs dealing with family, social, legal, medical, family mental health, etc. Where possible, provide enough details of prior intervention efforts to clarify what was attempted and whether it was successful.
These details will help give the treatment team an idea of what "target level" of adaptive functioning to shoot for in the current intervention.
Let the reader get an idea of how the current admission compares to prior admissions and what specific events precipitated the current admission. End this section with a brief paragraph summarizing staff observations, patient behavior, level of motivation, etc.
Keep in mind that objective observations by professional staff are one of your best sources of data.
Conclude with a sentence indicating medications being taken at the time of testing. Focus on YOUR observations and impressions. This section of the report should focus on your objective evaluation.
Avoid quoting the patient's opinion of his own mood, affect, etc. It's also best to avoid mixing in background information or test information with this section.
A typical MSE for a 'normal' patient might read: Results of mental status examination revealed an alert, attentive individual who showed no evidence of excessive distractibility and tracked conversation well.
The patient was casually dressed and groomed. Orientation was intact for person, time and place. Eye contact was appropriate. There was no abnormality of gait, posture or deportment.students use the same vocabulary quite differently, ascribing quite different meanings to words such as “fair,” “professional,” “organized,” “challenging,” and “respectful” (Lauer, ).
Reentry adults’ multiple roles and commitments increase the likelihood they will look for degree and certificate programs that provide them flexibility in time and locations for both course completion and for access to key student services. Adult Health History Form.
TB Test Report. School Physical. Pain Level Chart. Flu Shot Consent Form. Patient Discharge Form.
Patient Sign-In. SOAP Notes. SOAP Note with Body. Return to Work or School Form. Insurance Verification Sheet. Therapy Intake Form. Medical Report. Initial Exam Report. Pain Assessment Sheet If you don't see a medical.
One way you can do this is by numbering each return envelope and keeping a copy of the mailing list with matching numbers -- for example, if John Doe at Main Street is assigned number , then the number will also be on his return envelope.
Results of psychological evaluation reveal an extended history of alcohol abuse and a psychotic disorder characterized primarily by disturbance of thought content, with relative integrity of thought process and no clear indication of perceptual disturbance.
Description: SPR is conducting a month evaluation of seven Second Chance Act adult offender re-entry demonstration projects funded by BJA in The evaluation includes impact, process and outcome analyses and cost assessments of re-entry services provided by the sites.