Observed Status

Appearance:

Behavior / cooperation:

Speech:

Mood:

Affect:

Thought process:

Thought content (SI / HI / paranoia / AH / VH):

Perception:

Cognition / orientation:

Insight:

Judgment:

Suicidal ideation (current / past / none; plan or intent if present):

Homicidal ideation (current / past / none):

Cognitive screen (MoCA / MMSE / orientation x3 result):

Risk and Reliability

SI/HI, self-harm, aggression, psychosis, mania, intoxication, withdrawal, and protective factors.

State whether findings were observed, client-reported, collateral-reported, or limited by telehealth context.

Complete a C-SSRS / SAFE-T from the patient's current responses when suicidal ideation, self-harm, acute risk, or default risk placeholders are present.

Focus	Documentation
Assessment	Clinical impression, response to interventions, progress toward goals, risk, and medical necessity. Clinical impression: Progress / response: Risk status:
Interventions	Document interventions delivered, skills practiced, education, coordination, and patient engagement. Interventions today: Patient response: Coordination / education:
Plan	Next focus, homework or protocol changes, referrals/orders, monitoring, and appointment cadence. Next steps: Home practice / instructions: Follow-up:

Focus

Documentation

Assessment

Clinical impression, response to interventions, progress toward goals, risk, and medical necessity.

Clinical impression:

Progress / response:

Risk status:

Interventions

Document interventions delivered, skills practiced, education, coordination, and patient engagement.

Interventions today:

Patient response:

Coordination / education:

Plan

Next focus, homework or protocol changes, referrals/orders, monitoring, and appointment cadence.

Next steps:

Home practice / instructions:

Follow-up: