1. Please identify the patient case (or process) to present/review at the next ECHO clinic. Select a case that you would like to receive feedback on from the expert ECHO team. If possible, attempt to identify a case that relates to the topic of the day 2. Briefly describe relevant aspects of your case and draft your question(s) for the ECHO team using the Case Review Form 3. It is not necessary to complete every field on the Case Review Form, only those you think are relevant. Please comply with HIPAA regulations and do not use any Patient Identifiers when submitting cases for review 5. Be prepared to present the case in 20 minutes or less
Your Name (first and last name):
* must provide value
Your Location:
* must provide value
Your E-mail:
* must provide value
What is your main question(s) for the ECHO clinic about this patient?
What health, wellness, and co-occurring medical conditions are you hoping to discuss?
When do you plan to present this case review form?
Today M-D-Y
Prior ECHO consultation on this patient?
Yes
No
Which NAVIGATE FEP ECHO has this patient been presented at previously?
Diagnostic Assessment Health, Wellness and Co-Occurring Disorders Psychopharmacology Psychotherapy
Today M-D-Y
Hispanic or Latino NOT Hispanic or Latino Unknown / Not Reported
American Indian/Alaska Native Asian Native Hawaiian or Other Pacific Islander Black or African American White More Than One Race Unknown / Not Reported
Assigned sex at birth - What sex was the patient assigned at birth, on an original birth certificate?
Male
Female
Current gender identity - How does the patient describe their gender? (check one)
Male
Female
Transgender
Does not identify as female, male, or transgender
Date of admission to NAVIGATE program
BMI on admission to the NAVIGATE program
Current Height (inches) nearest whole number
Current Weight (pounds) nearest whole number
Current BMI (will be calculated for you)
View equation
When was the approximate onset of the auditory hallucinations?
Today M-D-Y
When was the approximate onset of the visual hallucinations?
Today M-D-Y
When was the approximate onset of the delusions?
Today M-D-Y
When was the approximate onset of the disorganized speech and behavior?
Today M-D-Y
When was the approximate onset of suicidal ideation?
Today M-D-Y
When was the most recent suicidal act?
Now M-D-Y H:M
How many prior suicidal acts?
When was the approximate onset of homicidal ideation?
Today M-D-Y
When was the prior act of aggression, approximately?
Today M-D-Y
Is the patient currently taking any psychiatric or nonpsychiatric medications?
* must provide value
Yes
No
How many psychiatric medications is the patient taking?
Psychiatric Medication Number 1
mg g mcg mL L Unit IU Percent Fluid Oz Other Unknown
one two three four other
Oral Topical Rectal Intravenous Intramuscular Subcutaneous Sublingual Inhalation Ocular Auricular Other Unknown
If other route of administration, specify:
Today M-D-Y
What has been the patient's response to the medication? (only need to answer for psychiatric medications)
complete control of symptoms partial control of symptoms not effective adverse events did not allow the continuation of the medication other
Are there any issues with adherence?
Yes
No
Please elaborate on adherence issues related to this medication:
Yes
No
Please describe the adverse event?
Psychiatric Medication Number 2
mg g mcg mL L Unit IU Percent Fluid Oz Other Unknown
one two three four other
Oral Topical Rectal Intravenous Intramuscular Subcutaneous Sublingual Inhalation Ocular Auricular Other Unknown
If other route of administration, specify:
Today M-D-Y
complete control of symptoms partial control of symptoms not effective adverse events did not allow the continuation of the medication other
Are there any issues with adherence?
Yes
No
Please elaborate on adherence issues related to this medication.
Yes
No
Please describe the adverse event?
Psychiatric Medication Number 3
mg g mcg mL L Unit IU Percent Fluid Oz Other Unknown
one two three four other
Oral Topical Rectal Intravenous Intramuscular Subcutaneous Sublingual Inhalation Ocular Auricular Other Unknown
If other route of administration, specify:
Today M-D-Y
What has been the patient's response to the medication? (only need to answer for psychiatric medications)
complete control of symptoms partial control of symptoms not effective adverse events did not allow the continuation of the medication other
Are there any issues with adherence?
Yes
No
Please elaborate on adherence issues related to this medication.
Yes
No
Please describe the adverse event?
Psychiatric Medication Number 4
mg g mcg mL L Unit IU Percent Fluid Oz Other Unknown
one two three four other
If other, please specify the frequency of dosing:
Oral Topical Rectal Intravenous Intramuscular Subcutaneous Sublingual Inhalation Ocular Auricular Other Unknown
If other route of administration, specify:
Today M-D-Y
What has been the patient's response to the medication? (only need to answer for psychiatric medications):
complete control of symptoms partial control of symptoms not effective adverse events did not allow the continuation of the medication other
Are there any issues with adherence?
Yes
No
Please elaborate on adherence issues related to this medication.
Any adverse events to this medication?
Yes
No
Please describe the adverse event?
Psychiatric Medication Number 5
mg g mcg mL L Unit IU Percent Fluid Oz Other Unknown
one two three four other
If other, please specify the frequency of dosing:
Oral Topical Rectal Intravenous Intramuscular Subcutaneous Sublingual Inhalation Ocular Auricular Other Unknown
If other route of administration, specify:
Today M-D-Y
What has been the patient's response to the medication? (only need to answer for psychiatric medications):
complete control of symptoms partial control of symptoms not effective adverse events did not allow the continuation of the medication other
Are there any issues with adherence?
Yes
No
Please elaborate on adherence issues related to this medication.
Yes
No
Please describe the adverse event?
Has the patient previously been on any other psychiatric medications?
Yes
No
Please elaborate on the previous psychiatric medications has the patient been on.
How many nonpsychiatric medications is the patient taking?
Nonpsychiatric Medication #1
mg g mcg mL L Unit IU Percent Fluid Oz Other Unknown
one two three four other
If other, please specify the frequency of dosing:
Oral Topical Rectal Intravenous Intramuscular Subcutaneous Sublingual Inhalation Ocular Auricular Other Unknown
If another route of administration, specify:
Today M-D-Y
Yes
No
Please describe the adverse event?
Nonpsychiatric Medication #2
mg g mcg mL L Unit IU Percent Fluid Oz Other Unknown
one two three four other
If other, please specify the frequency of dosing:
Oral Topical Rectal Intravenous Intramuscular Subcutaneous Sublingual Inhalation Ocular Auricular Other Unknown
If another route of administration, specify:
Today M-D-Y
Yes
No
Please describe the adverse event?
Nonpsychiatric Medication #3
mg g mcg mL L Unit IU Percent Fluid Oz Other Unknown
one two three four other
If other, please specify the frequency of dosing:
Oral Topical Rectal Intravenous Intramuscular Subcutaneous Sublingual Inhalation Ocular Auricular Other Unknown
If another route of administration, specify:
Today M-D-Y
Yes
No
Please describe the adverse event?
Nonpsychiatric Medication #4
mg g mcg mL L Unit IU Percent Fluid Oz Other Unknown
one two three four other
If other, please specify the frequency of dosing:
Oral Topical Rectal Intravenous Intramuscular Subcutaneous Sublingual Inhalation Ocular Auricular Other Unknown
If another route of administration, specify:
Today M-D-Y
Yes
No
Please describe the adverse event?
Nonpsychiatric Medication #5
mg g mcg mL L Unit IU Percent Fluid Oz Other Unknown
one two three four other
If other, please specify the frequency of dosing:
Oral Topical Rectal Intravenous Intramuscular Subcutaneous Sublingual Inhalation Ocular Auricular Other Unknown
If another route of administration, specify:
Today M-D-Y
Yes
No
Please describe the adverse event?
Does the patient have any prior psychiatric history? Please include any hospitalizations and their dates.
Please describe any history of trauma (physical, emotional, sexual)?
Does the patient have a history of Traumatic Brain Injury (TBI)?
Yes
No
If known, what was the approximate date the TBI occurred?
Today M-D-Y
Please describe any history of licit or illicit substance use
Please describe the patient's current family structure
Please describe any family psychiatric (depression, anxiety, mood, etc.) and medical history (diabetes, cardiovascular, cancer, hypertension, etc.)
Please describe any nonpsychiatric medical and surgical history
Please share a brief social history
Any allergies to medications?
Yes
No
Please describe. Things to include are the medication name(s) and reaction.
Please upload any relevant labs and progress notes here. If available, please provide CBC, CMP, TSH, lipid panel, and hemoglobin A1c lab values.
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