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DOCUSISTANT™ — Mental Health
DOCUSISTANT™ — Mental Health
Administrative
Date of service
Clinician (name + credentials)
Place of service
11 — Office
02 — Telehealth
12 — Home
03 — School
99 — Other
Session start / end times
to
Total minutes
Diagnosis & Context
ICD-10 category
Specific diagnosis
Psychosocial stressor (Z55–Z65)
Additional context / stressors
Mental Health Assessment
When did symptoms begin?
Within the past 2 weeks
Within the past month
About 3 months ago
About 6 months ago
More than a year ago
Since childhood/adolescence
Change since last visit
Improved
Unchanged
Worsened
Severity level
Mild
Moderate
Severe
Triggers or aggravating factors
Work stress
Family conflict
Financial strain
Sleep disruption
Health concerns
Substance use
Grief/Loss
Helpful coping strategies
CBT skills
DBT skills
Mindfulness
Behavioral activation
Social support
Sleep hygiene
Exercise
Risk assessment summary
Denies SI/HI
Passive SI, no plan/intent
Active SI without plan
Active SI with plan (safety planned)
No acute risk identified
Protective factors present
Functional domains impacted
Work / School
Social / Family
ADL
Legal
Mental Status Exam (MSE)
Appearance
well-groomed
neat
disheveled
unkempt
Dress appropriateness
appropriate
casual
unusual
inappropriate
Orientation
oriented ×3
partially oriented
disoriented
Motor activity
normal
agitated
retarded
tremulous
Speech (rate/volume/tone)
normal rate and tone
rapid/pressured
slow/soft
loud
monotone
Mood (reported)
"okay"
"anxious"
"depressed"
"irritable"
"angry"
"euthymic"
Affect
congruent
restricted
flat
labile
incongruent
Thought process
logical and goal-directed
tangential
circumstantial
flight of ideas
disorganized
Thought content
within normal limits
ruminative
obsessional
delusional
suicidal ideation without plan
suicidal ideation with plan
homicidal ideation
Perceptions
intact
auditory hallucinations
visual hallucinations
illusions
Attention / concentration
good
fair
poor
Memory
intact
impaired
recently impaired
remote impaired
Insight
good
fair
limited
poor
Judgment
good
fair
impaired
Impulse control
intact
reduced
impaired
Overall functional status
intact
mildly impaired
moderately impaired
severely impaired
Psychotherapy
Psychotherapy minutes
Engagement level
Fully engaged
Distracted
Resistant
Insight / skills uptake
Strong insight and skill use
Emerging insight
Limited insight
Techniques used
Cognitive Challenging
Cognitive Reframing
DBT
Mindfulness Training
Psychoeducation
Supportive Reflection
Problem-Solving
Behaviors observed
Tearful
Calm / Relaxed
Participated Actively
Requested Support
Required Redirection
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