National Health Data Systems, Inc.

Clinical Data Sets

In addition to managing a full range of biomedical/physiological diagnostic, treatment, and outcomes data, the following biopsychosocial data (including cognitive, behavioral, emotional, social, and mind-body interaction data) are managed.

 

Current Biopsychosocial Symptoms/Dysfunctions

  1. Factitious disorders
  2. Disturbances of consciousness and orientation
  3. Levels of alertness, attention, concentration, vigilance, concentration (vigilance deficits and attentional excesses)
  4. Memory problems and amnesia including psychogenic fugue, immediate and short-term memory impairment, recent and remote memory impairment, paramnesia, eidetic image, general memory impairment information
  5. Abstract thinking, intelligence, dementia, pseudodementia
  6. Problems with insight and judgment
  7. Executive functioning impairment and non-verbal communication learning disabilities (including dyslexia, dyscalculia, dysgraphia, directionality difficulty)
  8. Disorders of receptive communication (including verbal-receptive learning disabilities)
  9. Disorders of expressive communication (including verbal-expressive learning disabilities)
  10. Disturbances of thought process and form
  11. Hallucinations and illusions
  12. Perceptual agnosias
  13. Conversion disturbances
  14. Delusions
  15. Obsessions
  16. Peculiar, odd, eccentric behavior or appearance including inappropriate hygiene and dress, inappropriate eye contact, abnormal eye movement, and other peculiar, odd, or symptomatic facial or bodily movements and appearance
  17. Poor physical appearance - real or imagined, including overconcern with body shape or size
  18. Grossly defective/disorganized behavior
  19. Post-traumatic stress reaction symptoms
  20. Excesses of emotional, mood, affective including anger toward others/resentment, anger toward oneself, depression, anxiety, guilt, shame/embarrassment, jealousy/envy, pessimistic about the future, manic periods/emotional excitability, low frustration tolerance, easily irritated/annoyed, impatient, lack of adequate temper control
  21. Deficits of emotions, mood, affect including lack of pleasure/enjoyment; feelings of boredom/emptiness; flat or grossly inappropriate affect; unawareness of one's emotions; apathy; lack of empathy, remorse, tender emotions, and cool indifference
  22. Instability of emotions, mood, affect including bipolar symptoms
  23. Excesses of activity, drive, impulse, behavior including compulsions and restlessness; psychomotor agitation or tension; hyperactivity and poor impulse/urge control; reckless behavior; failure to adequately consider the consequences to one's actions; poor or lack of planning & decision-making; indecisiveness; kleptomania, pathological gambling, pyromania, trichotillomania, compulsive sexual activity with others, compulsive spending, compulsive masturbating; coprolalia, workaholism
  24. Deficits of activity, drive, impulse, behavior including poor work effort/motivation; loss of initiative; disinterest; poor planning; failure to persist on task; procrastination; difficulty making decisions; passive-aggressive behavior; irresponsible behavior: financial and parental irresponsibility; psychomotor retardation, lethargy; lacks activities of daily living (ADL) skills
  25. Identity problems and confusion including multiple personality symptoms, depersonalization and derealization symptoms, gender-identity problems
  26. Self-directed violence/aggression including suicidal and self-mutilation behavior
  27. Other-directed violence/aggression and anti-social behaviors including violent and non-violent conduct problems
  28. Interpersonal rejection, avoidance, abandonment: isolation of others by self including lack of generosity, lack of cooperative spirit, general negative view of others; social withdrawal; avoidance; reluctance to enter relationships; isolation; under socialization; interpersonal indifference; shyness
  29. Interpersonal rejection, avoidance, abandonment: isolation of self by others
  30. Interpersonal dependency, passivity, loneliness including insecurity, passivity/unassertiveness, proneness to peer-pressure, distressed being alone, devastated by relationship breakup, pattern of unstable/poor relationships
  31. Eating problems including excessive eating (overeating), poor appetite, excessive dieting or fasting, vomiting or use of laxatives, binging and purging, body weight, information regarding behavior & attitudes about eating
  32. Sleeping problems including hours of sleep per night, insomnia, hypersomnia, other sleeping problems
  33. Sexual problems and issues including sexual abuse; general information; violent sexual thoughts and fantasizes, exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, transvestic fetishism, voyeurism, other paraphilias; sexual dysfunctions; prostitution
  34. Physiological symptoms/somatization including gastrointestinal symptoms; pain symptoms autonomic nervous system symptoms; motor tension and overactivity; cardiopulminary symptoms; motor lethargy; numbness; tingling sensations; paralysis; sexual symptoms, female reproductive symptoms
  35. Psychological symptoms that may be presenting as or exacerbating physiological problems

Existing and Recently Past Environmental Stressors
Related to Biopsychosocial Symptoms/Dysfunctions

  1. Current interpersonal problems with birth parents; step, adoptive, foster parents; siblings; children; spouse, boyfriend, girlfriend, fiancé; extended family; coworkers or classmates; friends; authority; other interpersonal issues
  2. Victim of serious accident or crime
  3. Other current psycho-social problems including current problems with work or school, running away from home, current problems with living situation or working environment, current legal problems, current financial problems, other recent problems

Biomedical and Psychological Perspectives
Concerning Biopsychosocial Symptoms/Dysfunctions

Biomedical Perspectives

  1. Non-prescribed psychoactive substance use including, for example, caffeine, nicotine, alcohol, amphetamines, cannabis, cocaine, hallucinogens, inhalants, opioids, phencyclidine (PCP), sedatives, anabolic steroids
  2. Prescribed medications that may cause, exacerbate, or present as mental symptoms/dysfunctions including analgesic and anti-inflammatory drugs, antihistamines, antialcohol drugs, antibacterial and antifungal drugs, anticholingeric agents, anticonvulsants, antihypertensive and cardiac agents, antineoplastic drugs, antituberculosis drugs, hormones and steroids, neurological agents, other drugs
  3. Existing biomedical illnesses/diseases/insults that may cause, exacerbate, or present as mental symptoms/dysfunctions including poisons, intracranial disorders, endocrine dysfunction (hypo- or hyperfunction), disease of nonedocrine organs, central nervous system diseases, inflammatory disorders, skin disorders, other disorders
  4. Other biomedical information, exercise, diet, head injury, birth trauma, childhood ear infections, developmental milestone delays, exposure to hazardous or toxic substances, substance use by mother during pregnancy
  5. Biomedical lab tests and other physiological data including vital signs, imaging findings (such as X-Ray, PET, CAT, MRI), and lab test results (such as general blood and urine screenings, micro-biology, virology, cytopathology, histopathology, cytogenetics)

Psychological Perspectives

  1. Influence of general maladaptive cognitive styles on mental symptoms/dysfunctions including ultra-conservatism (avoids constructive risk-taking); pessimism, helplessness, hopelessness, lack of self-efficacy; perfectionism; inflexibility; dogmatic style; preoccupation with organization/order; paranoid ideation (non-delusional); lack of trust; suspiciousness
  2. Exaggerates the likelihood or adverse effect of occurrences
  3. Influence of specific cognitive schemas on emotional dysfunction

·        Primary dysfunctional cognitive schemas including irrational beliefs, negative self-concept and global self-appraisals, non-delusional inflated appraisals of self such as narcissism, self-centeredness, grandiosity, attention/approval-seeking; manipulative behavior; exhibitionism; negative global appraisals of others/prejudice

·        Secondary dysfunctional cognitive schemas including low self-efficacy; pessimistic future expectations; sense of wrongness, unfairness, entitlement/deservingness; causal attributions (responsibility)

  1. Coping attempts and outcomes
  2. Defense mechanisms employed including mature defenses, neurotic defenses, immature defenses, and narcissistic defenses
  3. Early (childhood) psycho-social experiences
  4. Ongoing assessment of the treatment process by patient and clinician including patient satisfaction survey and clinician's perception of patient/client's level of cooperation and social resources
  5. Mental health care services history including previous diagnoses; degree of benefit of previous treatments; psychotropic medications use - antidepressants, mood stabilizers, neuroleptics (antipsychotics), anxiolic agents, hypnotics/sedatives, psychostimulants
  6. Other health care services history
  7. Demographic, occupational, financial, educational, and miscellaneous information including present living arrangements, ethnicity, religious information and spiritual focus, family origin, occupational information, family income, military service history, educational history, television watching amount, painful anniversary dates, lie scale, zip code 

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Revised June 25, 2001