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Pet Exam Form

This document is an emergency department mental health assessment form. It contains sections to assess a patient's behavior, mood, speech, thought process and content, sensorium and reasoning, activities of daily living, suicidal ideation, suicidal plan, and potential for violence. The form is used to evaluate indications for a mental health assessment such as depression, suicidal thoughts or actions, delusions, or altered mental status. It allows the assessing clinician to check off objective observations and subjective reports to guide further treatment in the emergency department.

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phat lipp
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118 views1 page

Pet Exam Form

This document is an emergency department mental health assessment form. It contains sections to assess a patient's behavior, mood, speech, thought process and content, sensorium and reasoning, activities of daily living, suicidal ideation, suicidal plan, and potential for violence. The form is used to evaluate indications for a mental health assessment such as depression, suicidal thoughts or actions, delusions, or altered mental status. It allows the assessing clinician to check off objective observations and subjective reports to guide further treatment in the emergency department.

Uploaded by

phat lipp
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Emergency Department

Mental Health Assessment Form

O Medical Screening Exam completed Patient Name


Indications for Mental Health Assessment:
0 Depression 0 History of attempted suicide 0 Drug overdose
O Feelings of hopelessness 0 Suicidal Ideation 0 Delusions
0 Flat affect 0 Manic status 0 Altered Mental Status
0 Self-mutilative actions 0 Violence toward persons or property
O Documented inability to maintain nutrition or safety
Assessed by -Time

O Fearful O Circumstantial
I BEHAVIOR'
Posture: O Angry O Precise
O Agitated O Other
O Normal
O Slumped O Shame
O Guilt THOUGHT CONTENT
O Rigid
O Indifference Delusions:
O Other
O Depressed • None
O Grandiose
• Normal SPEECH O Persecutory
O Abnormal Amplitude: O Self-accusatory
O Normal O Somatic
Expression: O Loud
O Unremarkable Check if"yes"
O Soft
O Immobile O Screaming 0 Feelings of influence
O Sad O Monotone Ideas of reference
O Worried 0 Depression
0 Angry Quality: LI Obsessions/Compulsions
13 Variable O Normal Phobic thoughts
0 Happy O Mute 0 Anxieties
O Other. O Answers only questions Depersonalization
LI rcverty Derealization
ve contact: U Other iiiusions
O Good Hallucinations
O Avoided Speed:
O Stared into space O Normal SENSORIUM & REASONING
0 Intense, fixed O Fast O Clear judgment
O Slow O
Attention span: Lacks judgment
O Pressured
O Satisfactory O Can follow directions
O Other
O Distractible O Patient understands why brought here
0 Poor THOUGHT PROCESS O Appropriate long/short term memory
Association: O Impaired short term memory
Motor Level'
O Logical O Impaired long term memory
O Normal
O Coherent
O Hypoactive
Tight ACTIVITIES OF DAILY LIVING'
O Hyperactive
O Blocking 0. Independent
Mannerisms: O Loose O Needs assistance
0 None O Incoherent O Unable to perform
0 Posturing O Clang (rhyming)
O Pacing
Stream of Thought:
0 Tics O SUICIDAL IDEATION
O Unremarkable
CI Hand wringing
O Buccolingual-Masticatory
LI Over inclusive
O Concrete 10 SUICIDAL PLAN
O Other
o Echolatic
MOOD O Joking O POTENTIALLY VIOLENT
O Flight of ideas
CI Relaxed
Anxious O Tangential
O
O Non-spontaneous

Physician Signature Date Time


Call in all Medipass
Date Time Initials

If no card on presentation call this number 1111.11.111,


PLHC: 10/03 JR PAWORD\MISTRIformslform 1 8.doc

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