From b6321f8442b8964b1b4d2e3cc45010398cd7fffe Mon Sep 17 00:00:00 2001 From: Art Eaton Date: Thu, 15 Jun 2017 16:59:50 -0400 Subject: [PATCH] Bio-Psychosocial Assessment --- bpa/README.md | 4 + bpa/info.txt | 1 + bpa/new.php | 259 ++++++++++++++++++++++++++++++++++++++++++++++++ bpa/report.php | 172 ++++++++++++++++++++++++++++++++ bpa/save.php | 101 +++++++++++++++++++ bpa/table.sql | 87 +++++++++++++++++ bpa/view.php | 260 +++++++++++++++++++++++++++++++++++++++++++++++++ 7 files changed, 884 insertions(+) create mode 100644 bpa/README.md create mode 100644 bpa/info.txt create mode 100644 bpa/new.php create mode 100644 bpa/report.php create mode 100644 bpa/save.php create mode 100644 bpa/table.sql create mode 100644 bpa/view.php diff --git a/bpa/README.md b/bpa/README.md new file mode 100644 index 0000000..9b75e25 --- /dev/null +++ b/bpa/README.md @@ -0,0 +1,4 @@ +# EHR_Forms +Optional clinical forms for LibreHealthEHR + +Bio-Psychosocial Assessment form diff --git a/bpa/info.txt b/bpa/info.txt new file mode 100644 index 0000000..6344459 --- /dev/null +++ b/bpa/info.txt @@ -0,0 +1 @@ +Bio-Psychosocial Assessment diff --git a/bpa/new.php b/bpa/new.php new file mode 100644 index 0000000..5ca88c7 --- /dev/null +++ b/bpa/new.php @@ -0,0 +1,259 @@ + + + + + + topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0> +
+
+
Counseling Assessment


+
[Save] +You must EDIT the form after saving and reviewing to finalize +[Don't Save]
+
+ + +Client and Service Information

+Name:  +

+ +Reason for Seeking Treatment/Treatment Status:
+(Include referral source and reason, services requested.)
+

+ +Presenting Problems/Symptoms: (Include specific behaviors and/or symptoms, age of onset, duration, frequency, and severity.)
+

+ +Personal and Family History (Include child/family factors that may have contributed to need for services; child welfare involvement including reason for removal of child; family history of criminal charges, mental health diagnoses or substance abuse and any family history of treatment.)
+

+ +Mental Status +

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+Appearance:
+ Stated Age
+ Younger than Stated Age
+ Older than Stated Age
+ Underweight
+ Petite
+ Average Size
+ Overweight

+		 +Coordination/Gait:
+ No Difficulty
+ Staggered
+ Shuffled
+ Clumsy

+
+Eye Contact:
+ Good
+ Brief/Fleeting
+ Avoided

+		 +Affect (Observed):
+ Normal/appropriate
+ Euthymic
+ Dysthymic
+ Flat
+ Vacilating/Labile
+ Superficial/Inconsistent with Mood

+
+Mood (Client's Description):
+ Calm
+ Happy
+ Irritated/Agitated
+ Anxious
+ Sad
+ Angry
+ Excited
+ Appropriate to Topic of Conversation
+ Inappropriate to Topic of Conversation

+		 +Speech/Stream of Thought:
+ Clear
+ Articulate
+ Unclear
+ Slow
+ Soft Spoken
+ Mumbled
+ Excessive/Rapid
+ Negative/Critical

+
+Thought Content:
+ + +		 +Intellectual Ability:
+ + +
+Attention/Concentration:
+ + +		 +Recall:
+ + +
+Memory:
+ + +		 +Insight:
+ + +
+Judgment:
+ + +		 +Impulse Control:
+ + +
+

+ +

Risk Assessment:
+ +

+ +Risk Factors:
+ Hx of Tx Non-Compliance
+ Hx/Px of Elopement
+ Hx of Multiple Dx
+ Prior Inpatient Treatment
+ Prior Homicide or Suicide Attempt
+ Self Injurious
+ Current Suicide Ideation
+ Imminent Risk of Harm to Self
+ Threats to Harm Others
+ Aggression
+ Current Homicidal Ideation
+ Imminent Risk of Harm to Others
+ Other Risk Factors Noted

+ +Risk Management (Include thorough evaluation of risk factors above and steps taken to manage the risk.)
+ +

+ +Diagnostic Impressions Include criteria for all diagnosis provided based on clinical interview with primary caretaker/observation of caregiver-child relationship
+ +

+ +Findings: +

+Axis I
+

+Axis II
+

+Axis III
+

+Axis IV
+

+Axis V/CGAS
+

+ +Eligibility Criteria

+ Client has an ICD-9-CM diagnosis in the following range: 294.80, 294.90, 300.00 through 305.90, 307.10, 307.23, 307.50 through 307.70, 308.00 through 312.40, 312.81 through 314.90; +

+ and client is enrolled in Special Education for Seriously Emotionally Disturbed (SED) or Emotionally Handicapped (EH) School Placement +

+ or client has scored a 60 or below on the Axis V Children's Global Assessment of Functioning Scale within the last 6 months +

+ OR client has an ICD-9-CM diagnosis of 295.00 through 298.90 (schizophrenia or other psychotic disorders, major depression or bipolar disorder) or 303.00 through 305.90 (substance abuse). +

+ Certification: There is adequate evidence to indicate that the client is AT RISK for a more intensive, restrictive and costly behavioral health placement and the client's condition and functional level cannot be improved with a less intensive service such as individual or family therapy or group therapy. +

+ +Recommendation/Plan: +
Indicate the number and type of therapy hours/units recommended per week to meet the client's needs based on chronicity and severity of the presenting problems(s). Consider the types (individual, parent, family) and locations (home, school, community) of sessions that will be required.
+

+

+ +

[Save] +[Don't Save]
+
+ + diff --git a/bpa/report.php b/bpa/report.php new file mode 100644 index 0000000..7c1bace --- /dev/null +++ b/bpa/report.php @@ -0,0 +1,172 @@ + + + + + + + topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0> + +
Counseling Assessment
 +

+ + +Client and Service Information +

+Name:  +

+ +Reason for Seeking Treatment/Treatment Status:
+ +

+ +Presenting Problems/Symptoms:
+ +

+ +Personal and Family History
+ +

+ +Note:   +Additional information on client placement history, previous treatment, medications, developmental history, medical history, school information, strengths, substance abuse history and legal history can be found in section 1 of documents on the "Intake Information Form". +
+
+ +Mental Status

+ +Appearance:     + +

+ +Coordination/Gait:     + +

+ +Eye Contact:     + +

+ +Affect (Observed):     + +

+ +Mood (Client's Description):     + +

+ +Speech/Stream of Thought:     + +

+ +Thought Content:     +

+Intellectual Ability:     +

+Attention/Concentration:     +

+Recall:     +

+Memory:     +

+Insight:     +

+Judgment:     +

+Impulse Control:     +

+Risk Assessment:     +

+ + +Risk Factors: + +

+ +Risk Management
+

+ +Diagnostic Impressions
+

+ + + +Findings: +

+Axis I: +

+Axis II: +

+Axis III: +

+Axis IV: +

+Axis V/CGAS: +

+ +Eligibility Criteria

+ +
+ +
+ +
+ +
+ +

+ +Recommendation/Plan: + + +

+Digital Signature:  diff --git a/bpa/save.php b/bpa/save.php new file mode 100644 index 0000000..9503dfe --- /dev/null +++ b/bpa/save.php @@ -0,0 +1,101 @@ + $var) { +$_POST[$k] = mysql_escape_string($var); +echo "$var\n"; +} +if ($encounter == "") +$encounter = date("Ymd"); +if ($_GET["mode"] == "new"){ +$newid = formSubmit("form_bpa", $_POST, $_GET["id"], $userauthorized); + +addForm($encounter, "Bio Psycho-Social Assessment", $newid, "bpa", $pid, $userauthorized); +}elseif ($_GET["mode"] == "update") { +sqlInsert("update form_bpa set pid = {$_SESSION["pid"]},groupname='".$_SESSION["authProvider"]."',user='".$_SESSION["authUser"]."',authorized=$userauthorized,activity=1, date = NOW(), +reason_seeking ='".$_POST["reason_seeking"]."', +presenting_problem ='".$_POST["presenting_problem"]."', +personal_family_history ='".$_POST["personal_family_history"]."', +appearance_age ='".$_POST["appearance_age"]."', +appearance_younger ='".$_POST["appearance_younger"]."', +appearance_older ='".$_POST["appearance_older"]."', +appearance_underweight ='".$_POST["appearance_underweight"]."', +appearance_petite ='".$_POST["appearance_petite"]."', +appearance_average ='".$_POST["appearance_average"]."', +appearance_overweight ='".$_POST["appearance_overweight"]."', +coordination_good ='".$_POST["coordination_good"]."', +coordination_staggered ='".$_POST["coordination_staggered"]."', +coordination_shuffled ='".$_POST["coordination_shuffled"]."', +coordination_clumsy ='".$_POST["coordination_clumsy"]."', +eye_good ='".$_POST["eye_good"]."', +eye_brief ='".$_POST["eye_brief"]."', +eye_avoid ='".$_POST["eye_avoid"]."', +affect_normal ='".$_POST["affect_normal"]."', +affect_euthymic ='".$_POST["affect_euthymic"]."', +affect_dysthymic ='".$_POST["affect_dysthymic"]."', +affect_flat ='".$_POST["affect_flat"]."', +affect_labile ='".$_POST["affect_labile"]."', +affect_superficial ='".$_POST["affect_superficial"]."', +mood_calm ='".$_POST["mood_calm"]."', +mood_happy ='".$_POST["mood_happy"]."', +mood_irritated ='".$_POST["mood_irritated"]."', +mood_anxious ='".$_POST["mood_anxious"]."', +mood_sad ='".$_POST["mood_sad"]."', +mood_angry ='".$_POST["mood_angry"]."', +mood_excited ='".$_POST["mood_excited"]."', +mood_appropriate_to_topic ='".$_POST["mood_appropriate_to_topic"]."', +mood_inappropriate_to_topic ='".$_POST["mood_inappropriate_to_topic"]."', +speech_clear ='".$_POST["speech_clear"]."', +speech_articulate ='".$_POST["speech_articulate"]."', +speech_unclear ='".$_POST["speech_unclear"]."', +speech_slow ='".$_POST["speech_slow"]."', +speech_soft ='".$_POST["speech_soft"]."', +speech_mumble ='".$_POST["speech_mumble"]."', +speech_excessive ='".$_POST["speech_excessive"]."', +speech_negative ='".$_POST["speech_negative"]."', +thought_content ='".$_POST["thought_content"]."', +intellectual_ability ='".$_POST["intellectual_ability"]."', +attention_concentration ='".$_POST["attention_concentration"]."', +recall ='".$_POST["recall"]."', +memory ='".$_POST["memory"]."', +insight ='".$_POST["insight"]."', +judgment='".$_POST["judgment"]."', +impulse_control='".$_POST["impulse_control"]."', +risk_assessment ='".$_POST["risk_assessment"]."', +risk_compliance ='".$_POST["risk_compliance"]."', +risk_elope ='".$_POST["risk_elope"]."', +risk_multi ='".$_POST["risk_multi"]."', +risk_inpatient ='".$_POST["risk_inpatient"]."', +risk_hxsuicide ='".$_POST["risk_hxsuicide"]."', +risk_injury ='".$_POST["risk_injury"]."', +risk_suicide ='".$_POST["risk_suicide"]."', +risk_self ='".$_POST["risk_self"]."', +risk_threat ='".$_POST["risk_threat"]."', +risk_aggression ='".$_POST["risk_aggression"]."', +risk_homicide_ideation ='".$_POST["risk_homicide_ideation"]."', +risk_harm ='".$_POST["risk_harm"]."', +risk_other ='".$_POST["risk_other"]."', +risk_management ='".$_POST["risk_management"]."', +presenting_problem ='".$_POST["presenting_problem"]."', +diagnostic_impressions ='".$_POST["diagnostic_impressions"]."', +axis1 ='".$_POST["axis1"]."', +axis2 ='".$_POST["axis2"]."', +axis3 ='".$_POST["axis3"]."', +axis4 ='".$_POST["axis4"]."', +axis5 ='".$_POST["axis5"]."', +criteria1 ='".$_POST["criteria1"]."', +criteria2 ='".$_POST["criteria2"]."', +criteria3 ='".$_POST["criteria3"]."', +criteria4 ='".$_POST["criteria4"]."', +criteria5 ='".$_POST["criteria5"]."', +recommendation ='".$_POST["recommendation"]."', +finalize ='".$_POST["finalize"]."' where id=$id"); +} + +$_SESSION["encounter"] = $encounter; +formHeader("Redirecting...."); +formJump(); +formFooter(); +?> diff --git a/bpa/table.sql b/bpa/table.sql new file mode 100644 index 0000000..974efec --- /dev/null +++ b/bpa/table.sql @@ -0,0 +1,87 @@ +CREATE TABLE IF NOT EXISTS form_bpa ( + `id` bigint(20) NOT NULL AUTO_INCREMENT, + `date` datetime DEFAULT NULL, + `pid` bigint(20) DEFAULT NULL, + `user` varchar(255) COLLATE utf8_unicode_ci DEFAULT NULL, + `groupname` varchar(255) COLLATE utf8_unicode_ci DEFAULT NULL, + `authorized` tinyint(4) DEFAULT NULL, + `activity` tinyint(4) DEFAULT NULL, + `reason_seeking` longtext COLLATE utf8_unicode_ci NOT NULL, + `presenting_problem` longtext COLLATE utf8_unicode_ci NOT NULL, + `personal_family_history` longtext COLLATE utf8_unicode_ci, + `appearance_age` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `appearance_younger` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `appearance_older` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `appearance_underweight` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `appearance_petite` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `appearance_average` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `appearance_overweight` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `coordination_good` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `coordination_staggered` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `coordination_shuffled` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `coordination_clumsy` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `eye_good` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `eye_brief` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `eye_avoid` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `affect_normal` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `affect_euthymic` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `affect_dysthymic` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `affect_flat` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `affect_labile` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `affect_superficial` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `mood_calm` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `mood_happy` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `mood_irritated` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `mood_anxious` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `mood_sad` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `mood_angry` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `mood_excited` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `mood_appropriate_to_topic` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `mood_inappropriate_to_topic` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `speech_clear` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `speech_articulate` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `speech_unclear` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `speech_slow` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `speech_soft` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `speech_mumble` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `speech_excessive` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `speech_negative` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `thought_content` varchar(255) COLLATE utf8_unicode_ci NOT NULL, + `intellectual_ability` varchar(255) COLLATE utf8_unicode_ci NOT NULL, + `attention_concentration` varchar(255) COLLATE utf8_unicode_ci NOT NULL, + `recall` varchar(255) COLLATE utf8_unicode_ci NOT NULL, + `memory` varchar(255) COLLATE utf8_unicode_ci NOT NULL, + `insight` varchar(255) COLLATE utf8_unicode_ci NOT NULL, + `judgment` varchar(255) COLLATE utf8_unicode_ci NOT NULL, + `impulse_control` varchar(255) COLLATE utf8_unicode_ci NOT NULL, + `risk_assessment` longtext COLLATE utf8_unicode_ci NOT NULL, + `risk_compliance` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `risk_elope` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `risk_multi` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `risk_inpatient` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `risk_hxsuicide` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `risk_injury` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `risk_suicide` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `risk_self` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `risk_threat` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `risk_aggression` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `risk_homicide_ideation` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `risk_harm` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `risk_other` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `risk_management` longtext COLLATE utf8_unicode_ci NOT NULL, + `diagnostic_impressions` longtext COLLATE utf8_unicode_ci NOT NULL, + `axis1` longtext COLLATE utf8_unicode_ci NOT NULL, + `axis2` longtext COLLATE utf8_unicode_ci NOT NULL, + `axis3` longtext COLLATE utf8_unicode_ci NOT NULL, + `axis4` longtext COLLATE utf8_unicode_ci NOT NULL, + `axis5` longtext COLLATE utf8_unicode_ci NOT NULL, + `criteria1` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `criteria2` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `criteria3` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `criteria4` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `criteria5` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + `recommendation` longtext COLLATE utf8_unicode_ci NOT NULL, + `finalize` varchar(3) COLLATE utf8_unicode_ci DEFAULT NULL, + PRIMARY KEY (`id`) +) + diff --git a/bpa/view.php b/bpa/view.php new file mode 100644 index 0000000..5796024 --- /dev/null +++ b/bpa/view.php @@ -0,0 +1,260 @@ + + + + + + topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0> + +
" name="my_form"> +
Counseling Assessment


+
+ +[Save] +[Don't Save Changes]
+ > Check here to finalize this note:
+ ";?> + [RETURN TO ENCOUNTER] + +
+

+ + + +Client and Service Information

+Name:  +
+ +Reason for Seeking Treatment/Treatment Status:
+(Include referral source and reason, services requested.)
+

+ +Presenting Problems/Symptoms (Behavioral Stability)
+ +

+ +Personal and Family History (Include child/family factors that may have contributed to need for services; child welfare involvement including reason for removal of child; family history of criminal charges, mental health diagnoses or substance abuse and any family history of treatment.)
+

+ +Mental Status +

+Appearance:
+> Stated Age
+> Younger than Stated Age
+> Older than Stated Age
+> Underweight
+> Petite
+> Average Size
+> Overweight

+ +Coordination/Gait:
+> No Difficulty
+> Staggered
+> Shuffled
+> Clumsy

+ +Eye Contact:
+> Good
+> Brief/Fleeting
+> Avoided

+ +Affect (Observed):
+> Normal/appropriate
+> Euthymic
+> Dysthymic
+> Flat
+> Vacilating/Labile
+> Superficial/Inconsistent with Mood +

+ +Mood (Client's Description):
+> Calm
+> Happy
+> Irritated
+> Anxious
+> Sad
+> Angry
+> Excited
+> Appropriate to Topic of Conversation
+> Inappropriate to Topic of Conversation
+

+ +Speech/Stream of Thought:
+> Clear
+> Articulate
+> Unclear
+> Slow
+> Soft Spoken
+> Mumbled
+> Excessive/Rapid
+> Negative/Critical

+ + + + + + + + + + + + +
+ +Thought Content:
+ + +		 +Intellectual Ability:
+ + +
+Attention/Concentration:
+ + +		 +Recall:
+ + +
+Memory:
+ + +
+Insight:
+ + +		 +Judgment:
+ + +
+Impulse Control:
+ + +
+

+ + +

Risk Assessment:
+ +

+ + +Risk Factors:
+> Hx of Tx Non-Compliance
+> Hx/Px of Elopement
+> Hx of Multiple Dx
+> Prior Inpatient Treatment
+> Prior Homicide or Suicide Attempt
+> Self Injurious
+> Current Suicide Ideation
+> Imminent Risk of Harm to Self
+> Threats to Harm Others
+> Aggression
+> Current Homicidal Ideation
+> Imminent Risk of Harm to Others
+> Other Risk Factors Noted

+ +Risk Management
+ +

+ +Diagnostic Impressions
+ +

+ +Findings: +

+Axis I +

+Axis II +

+Axis III +

+Axis IV +

+Axis V/CGAS +

+ +Eligibility Criteria

+> Client has an ICD-9-CM diagnosis in the following range: 294.80, 294.90, 300.00 through 305.90, 307.10, 307.23, 307.50 through 307.70, 308.00 through 312.40, 312.81 through 314.90; +

+> and client is enrolled in Special Education for Seriously Emotionally Disturbed (SED) or Emotionally Handicapped (EH) School Placement +

+> or client has scored a 60 or below on the Axis V Children's Global Assessment of Functioning Scale within the last 6 months. +

+> OR client has an ICD-9-CM diagnosis of 295.00 through 298.90 (schizophrenia or other psychotic disorders, major depression or bipolar disorder) or 303.00 through 305.90 (substance abuse). +

+> Certification: There is adequate evidence to indicate that the client is AT RISK for a more intensive, restrictive and costly behavioral health placement and the client's condition and functional level cannot be improved with a less intensive service such as individual or family therapy or group therapy. +

+ +Recommendation/Plan:
+ +

+ +
+ +[Save] +[Don't Save Changes]
+ You must check the Finalize box at the top of the form to prevent future editing.
+ ";?> + [RETURN TO ENCOUNTER] + +
+ +