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Please add an additional tab on the subjective page for "Mental Health Factors"
The following are items requested to be included within the Mental Illness field, if it were to be added:
Communication / Interpersonal Skills
Ability to get needs met in community / self-advocacy
Adheres to social norms
Anger management
Argumentative
Assertiveness
Boundaries
Conflict resolution
Identifies/expresses feelings
Initiates contact
Nonverbal communication
Seeks support/reassurance
Verbal communication
Withdraws
Other:
Mood
Agitated
Angry
Anxious
Depressed
Elevated
Euphoric
Fearful
Irritable
Labile
Lethargic
Tense
Thought Process
Attention seeking
Avoidant
Confabulates
Confused
Dependent
Disoriented
Evasive
Guarded
Hallucinations
Homicidal ideation
Insight
Judgment
Limit testing
Loose
Manipulative
Paranoid
Reality orientation
Rigid
Self-awareness
Suicidal ideation
Tangential
Withdrawn
Cognitive Behavioral Function/Task Skills
Attention
Attention to detail
Concentration
Decision making
Error recognition/correction
Flexible
Follow-through
Follows direction
Frustration tolerance
Initiation
Memory
Motivation
Organization
Pacing
Perfectionistic
Planning
Problem Solving
Quality of work
Rigid
Self-confidence
Self-control
Self-efficacy
Self-image
Self-management
Self-regulation
Self-validation
Sequencing
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Hi Becca,
Thank you for considering above. Since March, our therapists have revised
the items we are requesting to be added and I reposted a new thread in the
SOAP idea portal. I will paste it below for your reference and
consideration.
Please add IADLS, Mood, Thought Process, Cognitive Behavioral
Functioning/Task Skills
*IADLS:*
Meal Prep**
ShoppingTransportationHome management**
Financial management
Managing medical conditions
Attending appointments
Managing medications***
*Communication/Social skills include:*
self-advocacy, adhering to social norms, anger management, assertiveness,
boundaries, conflict resolution, expressing feelings, initiates
conversations, seeks support, withdraws.
Other Items Needed in WebPT:
*MOOD:*
Agitated
Angry
Irritabile
Anxious
Depressed
Elevated
Euphoric
Fearful
Labile
Lethargic
Tense
*Thought Process:*
Attention seeking
Avoidant
Confabulates
Confused
Dependent
Disoriented
Evasive
Guarded
Hallucinations
Suicidal Ideation
Homicidal ideation
Insight
Judgment
Limit testing
Loose
Manipulative
Paranoid
Reality orientation
RigidSelf-awarenessTangential
*Cognitive Behavioral Functioning/Task Skills: (in addition to what WebPT
already has in cognitive communication tab)*
Attention to detail
Decision Making
Error Recognition
Flexibility
Frustration tolerance
Initiation
Motivation
Organization
Pacing
Perfectionistic
Planning
Quality of work
Rigid
Self-confidence
Self-control
Self-esteem
Self-management
Self-regulation
Sequencing
Time management
We also use the assessments OSA, MOHOST, MOCA/MMSE or SLUMS. Please add these if possible.
Please add OSA and MOHOST assessment
MOCA or MMSE
Many Occupational Therapist practice in Mental Health settings. Currently many OT's are using telehealth to treat this population.Plus these are areas that are seen across multiple disciplines and it is important that these skills are documented on. It would be very beneficial to have these as options to improve our documentation and make it easier. This will highly assist our practice moving forward with the COVID pandemic.
Our outpatient clinic specializes in serving clients with a mental health diagnosis. Our organization requires an EMR platform that includes these factors within the documentation. Due to the world pandemic, especially now more than ever, many practices would benefit from including these items.