If YES continue, If NO proceed to Section 3 |
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If both inpatient and outpatient mental health consults present: Select the consult that occurs first. |
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If YES continue, If NO proceed to Section 3 |
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Location consult: |
0 = Inpatient |
1 = Outpatient |
99 = Unk/not doc |
HISTORY AND MENTAL STATUS EXAM: |
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Depression Assessment (PHQ‐9/Diagnostic symptoms): |
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a. Low mood (dysphoria)/feeling down/depressed |
0 = No |
1 = Yes |
99 = Unknown/not doc |
b. Low interest (anhedonia)/little pleasure |
0 = No |
1 = Yes |
99 = Unknown/not doc |
c. Change in sleep (insomnia)/trouble falling asleep or staying asleep |
0 = No |
1 = Yes |
99 = Unknown/not doc |
d. Change in energy/ feeling tired/little energy |
0 = No |
1 = Yes |
99 = Unknown/not doc |
e. Change in guilt/feeling bad about yourself |
0 = No |
1 = Yes |
99 = Unknown/not doc |
f. Change in concentration/trouble concentrating on television or newspaper |
0 = No |
1 = Yes |
99 = Unknown/not doc |
g. Change in appetite/poor appetite/overeating |
0 = No |
1 = Yes |
99 = Unknown/not doc |
h. Change in psychomotor activity/moving slowly/speaking slowly or very restless/can't sit still. |
0 = No |
1 = Yes |
99 = Unknown/not doc |
i. Suicidal ideation |
0 = No |
1 = Yes |
99 = Unknown/not doc |
PTSD ASSESSMENT:C2, C4, C5, C6, C7, D1, and D5 |
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Criterion A: Was a trauma history elicited? |
0 = No |
1 = Yes |
99 = Unknown/not doc |
Criterion C: Avoidance and numbing. |
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a. Avoidance of thoughts, feelings, and conversations |
0 = No |
1 = Yes |
99 = Unknown/not doc |
b. Greatly reduced interest in related activities |
0 = No |
1 = Yes |
99 = Unknown/not doc |
c. Detachment or estrangement feelings |
0 = No |
1 = Yes |
99 = Unknown/not doc |
d. Restricted range of affect |
0 = No |
1 = Yes |
99 = Unknown/not doc |
e. Sense of a foreshortened future |
0 = No |
1 = Yes |
99 = Unknown/not doc |
Criterion D: Arousal |
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f. Difficulty sleeping |
0 = No |
1 = Yes |
99 = Unknown/not doc |
g. Exaggerated startled response |
0 = No |
1 = Yes |
99 = Unknown/not doc |