| RPT |
|CLINICAL PROGRESS REPORT||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.>
education)| <*Answer_4659*>|22. Provided housing support (e.g., location, placement, skills training, meetings)| <*Answer_4660*>|23. Provided vocational support (e.g., placement coaching,
skills training)| <*Answer_4661*>|24. Other service| <*Answer_4662*>|25. Was your MHICM team the primary provider of mental health services for this veteran during the past six months?|
<*Answer_4663*>|26. Which pattern of staff contact best describes your direct contacts with this veteran in the past six months?| <*Answer_4664*>|27. What percentage of your face-to-face contacts
with this veteran occurred in the community in the past six months?| <*Answer_4665*>|28. How far does this veteran live from your MHICM offices?| <*Answer_4666*>|29. How long does it take MHICM
staff to reach this veteran's home?| <*Answer_4667*>|30. Veteran, face-to-face contacts| <*Answer_4668*>|31. Veteran, phone/mail contacts| <*Answer_4669*>|32. Family| <*Answer_4670*>|33.
Non-family caregivers| <*Answer_4671*>|34. Community agencies| <*Answer_4672*>|35. In the past six months, in a typical week when you saw this veteran, how much total time did your team spend
providing direct services to him/her? (Exclude travel time without veteran.)| <*Answer_4673*>|36. ____ and I have a common perception of his/her goals| <*Answer_4674*>|37. The current goals of
our work together are important for ____| <*Answer_4675*>|38. I am cofident that I can help ____| <*Answer_5099*>|39. We are working towards mutually agreed upon goals| <*Answer_4676*>|40.
____ and I have built a mutual trust| <*Answer_4677*>|41. We have established a good understanding between us of the kinds of changes that would be good for ____| <*Answer_4678*>|42. Our
relationship is unimportant to ____| <*Answer_4679*>|43. Given all you know about this veteran's current life situation, how would you rate his/her present quality of life?| <*Answer_4680*>|44.
(<.Patient_Age.>)|Gender: <.Patient_Gender.>||||1. Staff Name:| <*Answer_4639*>|2. Today's Date:| <*Answer_4640*>|3. CPR Due Date:| <*Answer_4641*>|4. "Since" Date (IDF or Last CPR Due
How has this veteran's community adjustment changed in the past six months?| <*Answer_4681*>|45. What change in psychopathology do you feel this veteran has experienced as a result of his/her
participation in your program?| <*Answer_4682*>|46. Global Assessment Rating:| <*Answer_4683*>|48. In the past six months, was this veteran ever shifted to a lower level of care?|
<*Answer_4685*>|49. Clinically stable| <*Answer_4686*>|50. Not abusing addictive substances| <*Answer_4687*>|51. Not relying on extensive inpatient or emergency services| <*Answer_4688*>|52.
Capable of maintaining self in a community living situation| <*Answer_4689*>|53. Independently participating in necessary treatments| <*Answer_4690*>|54. Other criteria:| <*Answer_4691*>|55.
Shifted veteran to lower intensity services within the MHICM team| <*Answer_4692*>|56. Transferred veteran to lower services elsewhere| <*Answer_4693*>|57. Discharged veteran without additional
services| <*Answer_4694*>|58. Other treatment changes:| <*Answer_4695*>|59. When did this shift in treatment intensity occur?| <*Answer_4696*>|60. Was this veteran later shifted back to more
intensive services?| <*Answer_4697*>|61. Real or imminent danger to self or others?| <*Answer_4698*>|62. Psychiatric hospitalization| <*Answer_4699*>|63. Deterioration due to substance
abuse| <*Answer_4700*>|64. Impaired ability to care for self due to psychosis or stress| <*Answer_4701*>|65. Unwillingness/inability to participate in necessary treatments|
<*Answer_4702*>|66. Other reasons to restore more intensive services:| <*Answer_4703*>|67. Lower intensity case management services (caseload size > 20 per FTE)| <*Answer_4704*>|68. Day
treatment services| <*Answer_4705*>|69. Outpatient mental health services (individual/group therapy)| <*Answer_4706*>|70. Outpatient medication management/support| <*Answer_4707*>|71.
Date):| <*Answer_4642*>|5. Has this veteran terminated involvement with your program?| <*Answer_4643*>|6. Date of last contact while veteran was in MHICM:| <*Answer_4644*>|7. Veteran is
Substance abuse or dual diagnosis program/services| <*Answer_4708*>|72. Residential services (including CRC and therapeutic residence)| <*Answer_4709*>|73. Vocational services (including
supported employment)| <*Answer_4710*>|74. Inpatient mental health or medical services| <*Answer_4711*>|75. Nursing home care| <*Answer_4712*>|76. Other services received on a regular
basis:| <*Answer_4713*>|77. Did reducing the intensity of case management services for this veteran place him/her at undue risk?| <*Answer_4714*>| $~
deceased| <*Answer_4645*>|8. Cause of death| <*Answer_4646*>|9. Date of death:| <*Answer_4647*>|10. Veteran left the area/moved away| <*Answer_4648*>|11. Other reason(s) for termination:|
<*Answer_4649*>|12. Maintained supportive contact by telephone, mail or casual visits.| <*Answer_4650*>|13. Actively monitored use of resources and/or adherence to treatment.|
<*Answer_4651*>|14. Provided rehab counselling or skills training.| <*Answer_4652*>|15. Engaged in "psychotherapeutic" relationship using concepts from psychodynamic, behavioral,
cognitive-behavioral, family-systems or other model of therapy.| <*Answer_4653*>|16. Organized social or recreational activities in the community.| <*Answer_4654*>|17. Provided
education/support to family or non-family caregivers.| <*Answer_4655*>|18. Intervened in crisis situation with veteran, family or caregiver.| <*Answer_4656*>|19. Managed psychiatric medications
(e.g., prescription, pouring, delivery)| <*Answer_4657*>|20. Provided screening or care for medical problems.| <*Answer_4658*>|21. Provided substance abuse treatment (e.g., contracting,
|
