9. a.) Documented history of previous mental illness?0 = No 1 = Yes 99 = Unk/not doc | |||
(IF YES, CHOOSE ALL THAT APPLY) | |||
1 = Depression | 2 = Traumatic Brain Injury | ||
3 = Anxiety Disorder | 4 = PTSD | 5 = Bipolar Disorder | |
6 = Psychotic Disorder | 7 = Substance Abuse Disorder | 8 = Personality Disorder | |
9 = Other _____________ | |||
b.) Previous hospitalization for mental health condition? 0 = No 1 = Yes 99 = Unk/not doc | |||
(IF YES, CHOOSE ALL THAT APPLY) | |||
1 = Depression | 2 = Traumatic Brain Injury | ||
3 = Anxiety Disorder | 4 = PTSD | 5 = Bipolar Disorder | |
6 = Psychotic Disorder | 7 = Substance Abuse Disorder | 8 = Personality Disorder | |
9 = Other _____________ | |||
c.) Past suicidal ideation or attempt present? 0 = No 1 = Yes 99 = Unk/not doc | |||
b) If yes, indicate all classes of medications taken. | |||
…First examine Medications Tab. | |||
….Next in each clinic note examine for active medications. | |||
….Next go to Reports, clinical reports, pharmacy, all outpatient medications. | |||
(CHOOSE ALL THAT APPLY) | |||
1 = SSRI | 2 = SNRI | 3 = Mixed Class | 4 = Antipsychotics |
5= Mood stabilizers | 6=Benzodiazepines | 7 = other psychotropic (list ____________) | 99 = Unk/not doc |
(list specific drugs associated with PTSD Rx)______________________________________________________________ | |||
c) Is there evidence for past psychotherapy? | 0 = No | 1 = Yes | 99 = Unk/not doc |
(If yes list type of therapy provided or planned (e.g. PE, CBT, CPT, Supportive)____________________________) | |||
10. Psychiatric history | |||
1. First look on cover sheet for diagnoses – ensure that date of diagnosis falls within specified time frame if no MI | |||
2. Look in primary care notes under Past Medical History section if no MI | |||
3. Examine D/C summary section and look for admissions to psychiatry service | |||
Documented history of previous mental illness?0 = No 1 = Yes 99 = Unk/not doc | |||
(IF YES, CHOOSE ALL THAT APPLY) | |||
1 = Depression | 2 = Traumatic Brain Injury | ||
3 = Anxiety Disorder | 4 = PTSD | 5 = Bipolar Disorder | |
6 = Psychotic Disorder | 7 = Substance Abuse Disorder | 8 = Personality Disorder | |
9 = Other _____________ | |||
b.) Previous hospitalization for mental health condition? 0 = No 1 = Yes 99 = Unk/not doc | |||
(IF YES, CHOOSE ALL THAT APPLY) | |||
1 = Depression | 2 = Traumatic Brain Injury | ||
3 = Anxiety Disorder | 4 = PTSD | 5 = Bipolar Disorder | |
6 = Psychotic Disorder | 7 = Substance Abuse Disorder | 8 = Personality Disorder | |
9 = Other _____________ | |||
c.) Past suicidal ideation or attempt present? 0 = No 1 = Yes 99 = Unk/not doc | |||
FINAL ASSESSMENT | |||
1. Has a past or current diagnosis of PTSD | _____________ | ||
2. Has a past or current diagnosis of Depression | _____________ | ||
Score 1 – 5 | |||
3. Is currently being managed for PTSD and being monitored for symptoms of PTSD | _____________ | ||
4. Is currently being managed for PTSD and being monitored for symptoms of Depression | _____________ | ||
Score 1 – 5 | |||
5. Is currently being treated for PTSD with medications | _____________ | ||
6. Is currently being treated for Depression with medications | _____________ | ||
Score 1 – 5 | |||
7. Is currently being treated for PTSD with behavioral therapies | _____________ | ||
8. Is currently being treated for Depression with behavioral therapies | _____________ | ||
Score 1 – 5 | |||
Each of the four parameters will be assessed using a 5‐point Likert scale with the following categories: 1=definitely; 2=highly likely; 3=possibly; 4=highly unlikely; and 5=definitely not.