Psychiatric Attending Physician Statement Form Page 2
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1
2PART V: TREATMENT PLAN
PART V: TREATMENT PLAN
1. Nature of therapy and goals ___________________________________________________________________________________________
1. Nature of therapy and goals ___________________________________________________________________________________________
1.
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
2. Frequency of visits and length of therapy/counselling session _________________________________________________________________
2. Frequency of visits and length of therapy/counselling session _________________________________________________________________
2.
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
3. Date of most recent visit
3. Date of most recent visit
_
_
I
I
_
_
I________
I________
3.
YYYY
YYYY
MM
MM
DD
DD
4. Hospitalization dates - include admission/discharge summaries
4. Hospitalization dates - include admission/discharge summaries
4.
_________________________________________________________________________________
_________________________________________________________________________________
_
_
I
I
_
_
I________
I________
_________________________________________________________________________________
_________________________________________________________________________________
_
_
I
I
_
_
I________
I________
_________________________________________________________________________________
_________________________________________________________________________________
_
_
I
I
_
_
I________
I________
_________________________________________________________________________________
_________________________________________________________________________________
_
_
I
I
_
_
I________
I________
5. Medication
5. Medication
5.
Name
Name
Date started (YY|MM|DD)
Date started (YY|MM|DD)
Initial dosage
Initial dosage
Initial response
Initial response
Date of last dosage change
Date of last dosage change
(YY|MM|DD)
(YY|MM|DD)
Current dosage
Current dosage
Response
Response
Side-effects
Side-effects
Serum levels
Serum levels
Compliance
Compliance
Date medication discontinued
Date medication discontinued
(YY|MM|DD)
(YY|MM|DD)
6. Future treatment plans – what changes in treatment are being implemented or considered? __________________________________________
6. Future treatment plans – what changes in treatment are being implemented or considered? __________________________________________
6.
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
7.
7.
Additional diagnostic testing? __________________________________________________________________________________________
Additional diagnostic testing? __________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
8.
8.
Name of other health care providers
Name of other health care providers
Specialty
Specialty
Specialty
YYYY
YYYY
MM
MM
DD
DD
Counsellor _____________________________________
Counsellor _____________________________________
__________________________________
__________________________________
I
I
I______
I______
Therapist _____________________________________
Therapist _____________________________________
__________________________________
__________________________________
I
I
I______
I______
Other ________________________________________
Other ________________________________________
__________________________________
__________________________________
I
I
I______
I______
9.
9.
Is the patient following recommended treatment program?
Is the patient following recommended treatment program?
Yes
Yes
No
No
PART VI: ESTIMATED TIME FOR RECOVERY
PART VI: ESTIMATED TIME FOR RECOVERY
1.
1.
Patient Progress
Patient Progress
None
None
Regressed
Regressed
Minimal Improvement
Minimal Improvement
Significant Improvement
Significant Improvement
Plateaued
Plateaued
Resolved
Resolved
2.
2.
Patient Prognosis
Patient Prognosis
Poor
Poor
Good
Good
3.
3.
Which of your patient’s occupational duties are currently being affected by his/her condition? _______________________________________
Which of your patient’s occupational duties are currently being affected by his/her condition? _______________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
4.
4.
In your opinion, is the patient a suitable candidate for rehabilitation?
In your opinion, is the patient a suitable candidate for rehabilitation?
Yes
Yes
No
No
If no, explain.
If no, explain.
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
5.
5.
If unable to determine, follow up in ________________ weeks or _____________ months.
If unable to determine, follow up in ________________ weeks or _____________ months.
6.
6.
What is being done (or is needed) in the following areas to help your patient return to a productive lifestyle? (Tick all appropriate boxes)
What is being done (or is needed) in the following areas to help your patient return to a productive lifestyle? (Tick all appropriate boxes)
Physical conditioning
Physical conditioning
Stress management/coping skills
Stress management/coping skills
Social confidence-building
Social confidence-building
Vocational counseling
Vocational counseling
Other _________________________________________________________
Other _________________________________________________________
7.
7.
Any additional information or details that may have a significant impact on the patient’s recovery from this condition?
Any additional information or details that may have a significant impact on the patient’s recovery from this condition?
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Signature _____________________________________________________________ Date ___________________________________________
Signature _____________________________________________________________ Date ___________________________________________
® Saskatchewan Blue Cross is a registered trade-mark of the Canadian Association of Blue Cross Plans, used under license by Medical Services Incorporated, an independent licensee.
® Saskatchewan Blue Cross is a registered trade-mark of the Canadian Association of Blue Cross Plans, used under license by Medical Services Incorporated, an independent licensee.
MSI 382 09/13
MSI 382 09/13
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