Psychiatric Mental Health

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Trace DC10-10

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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Subjective — ask

  • Mood and interest — depressed mood, loss of pleasure, and the effect on daily life.
  • Neurovegetative symptoms — sleep, appetite, energy, and concentration.
  • Anxiety — worry, restlessness, and physical symptoms.
  • A direct, compassionate screen for thoughts of self-harm; if any are present, proceed to a risk assessment and the safety response (Section 12).
  • Psychiatric symptoms, substance use, recent stressors (detail in Psychosocial / Caregiver), and treatment adherence and side effects.
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