[NP-Clinical] mental health template/documentation

[Alfredo Bimbela]

I am working of downloading my templates as well. If you are mental health or not, you may want to consider the monthly Carlat Report. It is similar to the "Precribers Letter" in terms of usefulness.
   
  Also, people may want to review the findings from the STAR-D and STAR-BD studies. These are important studies to know if you are in mental health.
   
  http://www.edc.gsph.pitt.edu/stard/
   
  http://www.stepbd.org/ 

  Alfredo
  
"Rosales, Louise" <lrosales at smcvt.edu> wrote:
  Hi Lisa,

Here is one I used where I did my internship. you would have to modify it, because when it prints, the headers have the name of the agency where I was.

This is specifically for diagnosis and evaluation (D&E)

So, of all the forms I have used/see, this has been my favorite. It is also the only one on my computer:)

For follow up, for therapy I use a SOAP note form. When doing a med check, I make I cover SIGECAPS. If you are not familiar with that, here is a link to a great article:

http://www.aafp.org/afp/981101ap/carlat.html

Also, Carlat has a great interviewing and assessment guide: 
The The Psychiatric Interview: A Practical Guide (Practical Guides in Psychiatry) (Paperback) 
by Daniel J Carlat (Author)


Hope that helps
Louise

________________________________

From: np-clinical-bounces at nurse.net on behalf of Lisa Meyer
Sent: Fri 8/17/2007 10:59 AM
To: np-clinical at nurse.net
Subject: [NP-Clinical] mental health template/documentation


I am starting a new, part-time position in a few weeks in a university counseling center. I will primarily see students who have been evaluated by a counselor and sent to me either because they desire to try medication, are already on a med and need to maintain refills while at school, or want to discuss some aspect of medication management with me. Though I will not be providing counseling, during the initial evaluation I will need to confirm the counselor's diagnosis and discuss treatment options with the student. These visits are 40 min. and are more in-depth. I will see any student on meds at least every 2 weeks for a briefer (20 min.) appt. to assess SE's, compliance, efficacy, etc. They see thier counselor weekly between appt's with me.

I am looking to create some type of documentation template that I will be able to type my documentation on using my PC. We do not have transcriptionists, and my handwritting is not great. I think having one for each visit type would be best. I have searched the net looking for something I might modify, and am not coming up with much. Does anyone working in mental health have something they would be willing to share that might be helpful? 

Thanks!

Lisa
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