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Mental Status Exam

The document provides an overview of components included in a mental status exam and psychiatric inpatient progress note. The mental status exam includes assessments of appearance, behavior, mood, affect, thought processes, thought content, cognitive functioning, judgment, insight and impulse control. The psychiatric inpatient progress note template includes sections for the patient's subjective report, observations by staff, mental status exam, current medications, new labs, DSM diagnosis on different axes, documentation for continued hospitalization, and treatment plan. The global affect scale provides ratings from 100 to 0 to assess overall functioning, with lower scores indicating more severe impairment.

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DrLingaraju Hs
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2K views2 pages

Mental Status Exam

The document provides an overview of components included in a mental status exam and psychiatric inpatient progress note. The mental status exam includes assessments of appearance, behavior, mood, affect, thought processes, thought content, cognitive functioning, judgment, insight and impulse control. The psychiatric inpatient progress note template includes sections for the patient's subjective report, observations by staff, mental status exam, current medications, new labs, DSM diagnosis on different axes, documentation for continued hospitalization, and treatment plan. The global affect scale provides ratings from 100 to 0 to assess overall functioning, with lower scores indicating more severe impairment.

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DrLingaraju Hs
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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  • Mental Status Exam
  • Psych Inpatient Progress Note

Mental Status Exam

[Link] - Thanks rauls@[Link] General appearance & behavior: Dress/grooming Cooperativeness Eye contact Psychomotor agitation/retardation Attitude Bizarre mannerism/gestures/facial expressions Language: Native language/fluency Mood (how pt. feels): Dysphoric, euthymic, euphoric, hostile Affect (observed emotional state): Expansive, labile, normal, constricted, flat Appropriateness Thought Process (organization of thought): Speech: speed, volume, clarity Circumstantial, tangential, linear, flight of ideas, word salad Thought Content: Hallucinations (AH/VH) Delusions (persecution, grandiose, erotomanic, somatic) Suicidal/homicidal ideation (SI/HI) Derealization/depersonalization Cognitive: Level of consciousness: Alert/drowsy/stuporous Orientation: Person, place, date, situation (A+O x 4) Concentration: 1) Spell world backwards 2) Serial 7s or 3s 3) Months of year backwards Memory: 1) Immediate: Instant recall of 3 objects/digit span 2) Short term: Recall of 3 objects in 5 minutes 3) Long term: Ask about pts past hx General fund of knowledge:1) Current/past president 2) Historical events (9/11) Abstract thinking: Similarities/ Proverbs Judgement: Based on pts recent behavior: Is pt meeting social/family obligations Solutions to hypothetical situations (found stamped enevelope) Insight: Pts understanding of his/her illness, need for treatment Impulse control: Based on observation

Psych Inpatient Progress Note


Date/Time MS3 PN-Psychiatry S) 34 yo HM admitted for(e.g. major depression w/ psychosis) Pt. quote/ pt. subjective report of how he/she is doing, symptoms, feelings. Events since previous day, observations by staff (e.g. not taking meds, not sleeping, was restrained) O) Mental status exam Meds: Current meds Labs: New labs (e.g. Lith/Valproate levels, WBCs) A) Axis I/ Axis II/ Axis III/ Axis IV/ Axis V Any documentation for continued hospitalization (SI/HI, med refusal) P) Continue current med/management Day 8 of 14 day hold. Conservatorship/reise hearing scheduled.

Global Affect Scale


100-91 90-81 80-71 70-61 60-51 50-41 40-31 30-21 Superior fnxng, no sympt. Good functioning, absent/minimal sympt. Transient sympt/ expectable rxns to stressors Mild sympt. Moderate sympt. Serious sympt., impaired fnxng Impaired reality testing, major impairment in funxn/judge. ehavior considerably influenced by delusions/hallucination, inability to fnxn in almost all areas 20-11 Some danger harming self/others, grossly impaired comm. 10-1 Persistent danger of severely hurting self/others, suicidal act 0 Inadequate information

[Link] - Thanks rauls@[Link]

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