1 | P a g e Master Note Templates Valant built two master templates that can be used as a starting point for cloning to make custom notes. They are “MASTER Intake Note - All Tabs & Measures” and
Valant built two master templates that can be used as a starting point for cloning to make custom notes. They are “MASTER Intake Note - All Tabs & Measures” and “MASTER...
Master Note Templates Valant built two master templates that can be used as a starting point for cloning to make custom notes. They are "MASTER Intake Note - All Tabs & Measures" and "MASTER Progress Note - All Tabs & Measures". These templates contain all the tabs that can be configured to remove unwanted tabs and reorder tabs to practice preference. "MASTER Intake Note- All Tabs & Measures" includes the following tabs: Header Abuse Birth History Caregiver Comments Chief Complaint Community Resources Current Behavior Current Living Situation Developmental and Educational Hx Developmental History Developmental Milestones External Systems Family Background Family Hx Family Medical History Family Mental Health/Social History Family of Origin History Family Relationships Family Social History General Information General Social Hx Health Factors HPI Inpatient Hx Interview with Child Introductory Information Legal History Lifestyle Health Medical History Meds & Allergies Menstruation and Pregnancy Hx Mental Health Treatment /Evaluation History Outpatient Hx Past Medical Hx Patient Allergies Persons Present Prenatal Development and Birth History Presenting Problem - Intake Prior/Current Therapies Psychiatric Med Hx Reason for Referral Referral Relationship Information Review of Systems Social History Sources of Information Spiritual Orientation Stressors Substance Abuse Hx Substance Treatment Hx Substance Use Consequences Suicide/Self-Harm Hx Topics Discussed Trauma/Stressors Violence Hx Exam Lab Results Measure Review Time Spent Vital Signs Assessment - Informed Consent Assessment - Alternatives Considered Assessment - Diagnoses Assessment - Impression Assessment - Sources of Risk Counseling and Coordination of Care Free Form Content Physical Exam Review of Measures Risk Assessment Strengths Suicide Protective Factors Suicide Risk Factors Plan Plan - Labs Ordered Plan - Med Changes Plan - Next Appointment Psychotherapy Send Copy Suicide Prevention Plan Therapies Recommended Valant Treatment Plan Adult Symptom Screener Agoraphobia Sub-Scale AIMS ASAM 1|Page ASRS-V1.1 AUDIT BADS-SF BAM BDD-YBOCS CAGE-AID CES-DC Child Symptom Screener COWS C-SSRS - Full Scale, Clinician-administered, Lifetime-Recent C-SSRS - Full Scale, Clinician-administered, Lifetime-Recent C-SSRS - Screener, SelfReport, Recent CY-BOCS - Parent DASS-21 DASS-42 EDE-Q6 EPDS GAD-7 GDS-15 GDS-30 HDCL-C ICG IPDS LEC-5 Standard MEQ MoodDQ NIDA-Modified ASSIST PANSS PCL-5 PCL-5 Weekly PCL-C PCL-S PDSS PHQ-9 PSC QUIDS SCARED - Child SCARED - Parent SCARED - Parent - GAD Subscale SCARED - Parent - Panic Disorder Subscale SCARED - Parent Separation Anxiety Subscale SCARED - Parent Significant School Avoidance Subscale SCARED - Parent - Social Anxiety Subscale SEEK-PSQ Sheehan31 SPIN Suicide Ideation Subscale Trauma Questionnaire Vanderbilt - Parent Vanderbilt - Parent - ADHD Subscale Vanderbilt - Parent Conduct Disorder Subscale Vanderbilt - Parent - ODD Subscale Vanderbilt - Teacher WHO-5 WHODAS 2.0 Y-BOCS YMRS Y-PSC Review 2|Page "MASTER Progress Note- All Tabs & Measures" includes the following tabs: Header Adherence Chief Complaint Family Configuration Family System Functionality Health Factors History of Present Illness/Interval History Individual Function and Dysfunction Meds & Allergies Past History Persons Present Presenting Problem - Intake Presenting Problem Ongoing Review of Systems School Session Focus Side Effects Sources of Information Stressors Subjective (SOAP) Subjective/Objective Suicidal Ideation Treatment Approach EB Treatment Approach Exam Family and Environmental Strategies Homework Interventions Interventions Utilized Lab Results Last Session Homework Measure Review Objective (SOAP) Vital Signs Assessment - Informed Consent Assessment - Alternatives Considered Assessment - Diagnoses Assessment - Impression Assessment - Sources of Risk Assessment (SOAP) Clinical Global Impressions Condition Counseling and Coordination of Care Formulation Free Form Content Physical Exam Review of Measures Suicide Protective Factors Suicide Risk Assessment Introduction Suicide Risk Factors Systemic Assessment MFT Treatment Plan Plan Plan - Labs Ordered Plan - Med Changes Plan - Next Appointment Plan (SOAP) Psychotherapy Reason for Discharge Suicide Prevention Plan Therapy Plan Valant Treatment Plan Anxiety-related Disorders Child and Adolescent Dialectical Behavior Therapy Eating & Weight-related Disorders PIE - Effectiveness PIE - Intervention PIE - Purpose Adult Symptom Screener Agoraphobia Sub-Scale AIMS ASAM ASRS-V1.1 AUDIT BADS-SF BAM BDD-YBOCS CAGE-AID CES-DC Child Symptom Screener COWS C-SSRS - Full Scale, Clinician-administered, Lifetime-Recent C-SSRS - Full Scale, Clinician-administered, Since Last Contact C-SSRS - Screener, SelfReport, Recent CY-BOCS - Parent DASS-21 DASS-42 EDE-Q6 EPDS GAD-7 GDS-15 GDS-30 HDCL-C ICG IPDS LEC-5 Standard MEQ MoodDQ NIDA-Modified ASSIST PANSS PCL-5 PCL-5 Weekly PCL-C PCL-S PDSS PHQ-9 PSC QUIDS SCARED - Child 3|Page SCARED - Parent SCARED - Parent - GAD Subscale SCARED - Parent - Panic Disorder Subscale SCARED - Parent Separation Anxiety Subscale SCARED - Parent Significant School Avoidance Subscale SCARED - Parent - Social Anxiety Subscale SEEK-PSQ Sheehan31 SPIN Suicide Ideation Subscale Trauma Questionnaire Vanderbilt - Parent Vanderbilt - Parent - ADHD Subscale Vanderbilt - Parent Conduct Disorder Subscale Vanderbilt - Parent - ODD Subscale Vanderbilt - Teacher WHO-5 WHODAS 2.0 YMRS Y-PSC Review 4|PageMicrosoft Word for Office 365