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Suboption
No assessment procedures performed to date
Assessment procedures performed
History of psychological testing AND results / findings
Family psychiatric AND medical history
Patient psychiatric AND medical history
Co-occurring medical diagnoses
Co-occurring psychiatric diagnoses
Primary diagnosis
Gender
Age
Authorize up to 6h of neuropsychological testing
No medication / substance use
Substance abuse / dependence AND at least 10d sobriety
Patient on medication AND drug effects ruled out as cause of cognitive impairment
Previous testing performed
No previous neuropsychological testing
Multiple sclerosis AND suspected / demonstrated cognitive impairment
Epilepsy AND cognitive impairment suspected / demonstrated
Dementia / Mild cognitive impairment suspected / diagnosed
Brain tumor in remission / WITH slow progression
Authorize up to 10h of neuropsychological testing
No medication / substance use
Substance abuse / dependence AND at least 10d sobriety
Patient on medication AND drug effects ruled out as cause of cognitive impairment
Previous testing performed 1 to 2x AND neurologic deficit confirmed
No previous neuropsychological testing
Encephalitis / Meningitis
Cerebrovascular accident
Confirmed neurotoxin exposure
Hx of intracranial surgery
Anoxic / Hypoxic brain injury
Traumatic brain injury
Medication review
Personal AND family psychiatric
Personal AND family medical
Patient prefers ECT AND is capable of adherence
Current / Hx of medication refractory / resistant symptoms
Psychiatric medication contraindicated
Additional workup completed due to potential medical complications
No risk factors / signs of potential complications / comorbidities
Baseline BP
Review of systems
Medication review
Personal AND family psychiatric
Personal AND family medical
Previous positive responde to ECT
Psychiatric medication contraindicated
Acute symptoms refractory to medication
Catatonia
Positive psychotic symptoms AND confirmed schizophrenia / schizoaffective / schizophreniform disorder
Acute mania
Depression
Re-evaluation of plan effectiveness qd
15 min checks / PRN medication at least 1x/24h
Symptoms / Behavior increasing / uncontrolled
Medical intervention / treatment refused
Medical intervention / treatment refused
Involuntary admission awaiting probable cause / probate hearing
Medication adjustment w/in 48h
Medication initiated w/in 48h
Anticholinergics
Antianxiety
Antipsychotics
One-to-one
Constant D/C'd w/in last 24h
Constant
Serotonin syndrome
Neuroleptic malignant syndrome
Anticholinergic toxicity
Severe akathisia nonresponsive to medication adjustment
Dystonic reaction
Postural systolic BP drop ≥ 30
Systolic BP < 90 / Clinically significant hypotension
WBC < 1500/cu.mm (1.5 x 10 â¹/L) / Absolute neutrophil count < 500/cu.mm (500 x 10â¶/L)
Seizures
Heart rate < 50/min / > 120/min
Unable to follow instructions / negotiate needs
Impulsive / Agitated
Impaired nutritional status WITH weight loss
Sharps / Medications / Contraband found in patient's possession
Nonverbal / Refusal to disclose plan
Specific plan
Psychological
Behavioral
Somatic
Mild impairment
Moderate impairment
Severe impairment
Self-mutilation
Preoccupation with somatic symptoms unexplained by medical evaluation / unresponsive to treatment
Excessive / Inappropriate utilization of general / emergency medical services
Medication / Substance misuse
Psychiatric medication nonadherence
Psychological
Behavioral
Somatic
Medication / Substance misuse
Denies plan
Refusal to disclose plan
Nonspecific plan
Misinterpretations / Illusions / Hallucinations
Change in cognition
Unable to focus / sustain attention
Anxiety WITH associated symptoms AND substance use w/in last 24h
Amnesic event with unexplained / unaccounted disappearance
Refusal to disclose current plan
Attempt w/in last yr
Nonspecific plan WITH means AND no deterrents
Specific plan
Re-evaluation of plan effectiveness qd
15 min checks / PRN medication at least 1x/24h
Symptoms / Behavior increasing / uncontrolled
Medical intervention / treatment refused
Involuntary admission awaiting probable cause / probate hearing
Medication adjustment w/in 48h
Medication initiated w/in 48h
Anticholinergics
Antianxiety
Antipsychotics
One-to-one
Constant D/C'd w/in last 24h
Constant
Serotonin syndrome
Neuroleptic malignant syndrome
Anticholinergic toxicity
Severe akathisia nonresponsive to medication adjustment
Dystonic reaction
Postural systolic BP drop ≥ 30
Systolic BP < 90 / Clinically significant hypotension
WBC < 1500/cu.mm (1.5 x 10 â¹/L) / Absolute neutrophil count < 500/cu.mm (500 x 10â¶/L)
Seizures
Heart rate < 50/min / > 120/min
Sharps / Medications / Contraband found in patient's possession
Unable to follow instructions / negotiate needs
Nonverbal / Refusal to disclose plan
Specific plan
Verbal hostility
Destruction of property
Physical altercation
Unable to follow instructions / negotiate needs
Available AND competent
Expected to adhere with treatment
Available AND competent
Questionably competent
Expected to adhere WITH continued negotiation
Potential for nonadherence
Intentional sabotage of treatment
Ongoing contact with perpetrator of abuse
Unable to ensure safety
Unavailable
Expected to adhere WITH continued negotiation
Unable / Refuses to adhere with treatment
Arrest / Confirmed illegal activity
Unable to maintain residence / Eviction
Removal from current living situation by authorities
Exposes dependent children / vulnerable adults to physical / sexual abuse
Unable to care for / Neglect of dependent children / vulnerable adults
Unable to care for / Neglect of dependent children / vulnerable adults
Unemployed AND unable to seek work
Self-employed AND unable to maintain business
Medical LOA due to psychiatric disorder
Suspended / Terminated / Quit / Expelled from work / school
Absent at least 5d from work / 10d from school
Restraining order / Arrest due to domestic dispute
Significant relationship terminated
Physically abused / abusive
Sexually abused / abusive
Nonverbal
Socially withdrawn
Unable to perform daily tasks / activities even WITH assistance
Unable to nourish self even WITH assistance
Unable to attend to hygiene even WITH assistance
Nonambulatory
Mild impairment
Moderate impairment
Severe impairment
Self-mutilation
Hyperactive-impulsive
Fire setting
Psychiatric medication nonadherence
Medication / Substance misuse
Overdose from drug use / abuse AND medically stable
Angry outbursts
High-risk sexual activity
Destruction of property
Daredevil behavior
Shoplifting
Brandishing a weapon
Physical altercation
Medication / Substance misuse
Denies plan
Refusal to disclose plan
Nonspecific plan
Misinterpretations / Illusions / Hallucinations
Change in cognition
Unable to focus / sustain attention
Violence toward self / others
Severe impulsivity / agitation
Anxiety AND substance use w/in last 24h
Refusal to disclose current plan
Attempt w/in last yr
Nonspecific plan WITH means AND no deterrents
Specific plan
Re-evaluation of plan effectiveness qd
15 min checks / PRN medication at least 1x/24h
Symptoms / Behavior increasing / uncontrolled
Involuntary admission awaiting probable cause / probate hearing
Subsequent treatments
Initial w/in last 72h
Medication adjustment w/in 48h
Medication initiated w/in 48h
Anticholinergics
Antianxiety
Antipsychotics
One-to-one
Constant D/C'd w/in last 24h
Constant
Serotonin syndrome
Neuroleptic malignant syndrome
Anticholinergic toxicity
Severe akathisia nonresponsive to medication adjustment
Dystonic reaction
Postural systolic BP drop ≥ 30
Systolic BP < 90 / Clinically significant hypotension
WBC < 1500/cu.mm (1.5 x 10 â¹/L) / Absolute neutrophil count < 500/cu.mm (500 x 10â¶/L)
Seizures
Heart rate < 50/min / > 120/min
Unable to follow instructions / negotiate needs
Impaired nutritional status WITH weight loss / failed weight gain
Nonambulatory
Change in mental status
Sharps / Medications / Contraband found in patient's possession
Nonverbal / Refusal to disclose plan
Specific plan
Re-evaluation of plan effectiveness qd
15 min checks / PRN medication at least 1x/24h
Symptoms / Behavior increasing / uncontrolled
Medical intervention / treatment refused
Involuntary admission awaiting probable cause / probate hearing
Subsequent treatments
Initial w/in last 72h
Medication adjustment w/in 48h
Medication initiated w/in 48h
Anticholinergics
Antianxiety
Antipsychotics
One-to-one
Constant D/C'd w/in last 24h
Constant
Serotonin syndrome
Neuroleptic malignant syndrome
Anticholinergic toxicity
Severe akathisia nonresponsive to medication adjustment
Dystonic reaction
Postural systolic BP drop ≥ 30
Systolic BP < 90 / Clinically significant hypotension
WBC < 1500/cu.mm (1.5 x 10 â¹/L) / Absolute neutrophil count < 500/cu.mm (500 x 10â¶/L)
Seizures
Heart rate < 50/min / > 120/min
Unable to follow instructions / negotiate needs
Impaired nutritional status WITH weight loss
Nonambulatory
Change in mental status
Sharps / Medications / Contraband found in patient's possession
Nonverbal / Refusal to disclose plan
Specific plan
Available AND competent
Expected to adhere with treatment
Available AND competent
Questionably competent
Unable to manage intensity of symptoms
Expected to adhere WITH continued negotiation
Potential for nonadherence
Intentional sabotage of treatment
Ongoing contact with perpetrator of abuse
Unable to ensure safety
Unavailable
Expected to adhere WITH continued negotiation
Unable / Refuses to adhere with treatment
Arrest / Confirmed illegal activity
Unable to maintain residence / Eviction
Removal from current living situation by authorities
Exposes dependent children / vulnerable adults to physical / sexual abuse
Unable to care for / Neglect of dependent children / vulnerable adults
Unemployed AND unable to seek work
Self-employed AND unable to maintain business
Medical LOA due to psychiatric disorder
Suspended / Terminated / Quit / Expelled from work / school
Absent at least 5d from work / 10d from school
Physically abused / abusive
Physically abused / abusive
Restraining order / Arrest due to domestic dispute
Significant relationship terminated
Sexually abused / abusive
Nonverbal
Socially withdrawn
Unable to perform daily tasks / activities even WITH assistance
Unable to nourish self even WITH assistance
Unable to attend to hygiene even WITH assistance
Nonambulatory
Mild impairment
Moderate impairment
Severe impairment
Negative symptoms
Disorganized behavior
Disorganized speech
Hallucinations
Delusions
Comorbid medical condition
Medication / Substance misuse
Psychiatric medication nonadherence
Medication / Substance misuse
Denies plan
Refusal to disclose plan
Nonspecific plan
Misinterpretations / Illusions / Hallucinations
Change in cognition
Unable to focus / sustain attention
Brandishing a weapon
Fire setting
Substance use w/in last 24h
Refusal to eat / drink
Endangering behavior AND lack of insight / judgement
Increasing disorganized behavior
Violence toward other w/in last wk
Psychiatric medication nonadherence
Psychotic symptoms
Refusal to disclose current plan
Attempt w/in last yr
Nonspecific plan WITH means AND no deterrents
Specific plan
Available AND competent
Questionably competent
Unable to manage intensity of symptoms
Mild impairment
Moderate impairment
Severe impairment
Available AND competent
Expected to adhere with treatment
Expected to adhere WITH continued negotiation
Potential for nonadherence
Intentional sabotage of treatment
Ongoing contact with perpetrator of abuse
Unable to ensure safety
Unavailable
Expected to adhere WITH continued negotiation
Unable / Refuses to adhere with treatment
Arrest / Confirmed illegal activity
Unable to maintain residence / Eviction
Removal from current living situation by authorities
Exposes dependent children / vulnerable adults to physical / sexual abuse
Unable to care for / Neglect of dependent children / vulnerable adults
Unemployed AND unable to seek work
Self-employed AND unable to maintain business
Medical LOA due to psychiatric disorder
Suspended / Terminated / Quit / Expelled from work / school
Absent at least 5d from work / 10d from school
Restraining order / Arrest due to domestic dispute
Significant relationship terminated
Sexually abused / abusive
Nonverbal
Socially withdrawn
Unable to perform daily tasks / activities even WITH assistance
Unable to nourish self even WITH assistance
Unable to attend to hygiene even WITH assistance
Nonambulatory
Associated signs / symptoms / behavior
Hopelessness
Diminished ability to think / concentrate / make a decision
Feelings of worthlessness / Excessive guilt
Anhedonia / Loss of interest
Fatigue / Loss of energy
Psychomotor agitation / retardation
Insomnia / Hypersomnia
Poor appetite / Overeating
Medication / Substance misuse
Denies plan
Refusal to disclose plan
Nonspecific plan
Misinterpretations / Illusions / Hallucinations
Change in cognition
Unable to focus / sustain attention
Agitation / Anxiety AND substance use w/in last 24h
Refusal to disclose current plan
Attempt w/in last yr
Nonspecific plan WITH means AND no deterrents
Specific plan
Title
Instructions
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