Assignment Prompt & Instructions
– 2 years ago
**files (3)**
– ## 3GraduateMentalStatusExamGuidecopy3.docx
– GraduateComprehensivePsychiatricEvaluationandPsychotherapyNoteTemplaterev.3112022copy2.docx
– PsychiatricSOAPNoteRubric1copy2.docx
**## 3GraduateMentalStatusExamGuidecopy3.docx**
**MENTAL STATUS EXAM GUIDE**
Previous Mental Health Treatments (e g: psychopharmacology, inpatient stabilization, Occupational Therapy, Vocational Therapy, Marriage/Family Therapy, Group Therapy, Detox, ECT &/or social services):
What is the initial impression of the admitting examiner found in the initial evaluation, triage, or social worker note:
Compare your impression of the patient’s status now to the initial impression:
**BRIEF MENTAL STATUS EXAM**
Instructions; Most information can be obtained during an interaction with the patient without asking specific questions. The information must be described to support your conclusion.
GENERAL DESCRIPTION
Appearance (e.g. grooming, manner of dress, level of hygiene, facial expression, remarkable features, height, weight, nutritional status, presence of piercings, tattoos, scars, the relationship between appearance and age, etc.):
Attitude toward examiner
**(INCLUDED IN BEHAVIOR)** – Does the patient have good eye contact? Are they cooperative, friendly, attentive, interested, frank, seductive, defensive, playful, apathetic, evasive, guarded, etc.:
Speech characteristic –
What are the qualities of the patient’s speech include tone, inflection, volume, pronunciation (clear or slurred; mumbling; defects, lisp, stuttering), speed:
What is the quantity of the patient’s speech? Does the patient verbalizes freely, provide monosyllabic answers, have pressured speech, and/or are they hyperverbal:
Psychomotor activity
**(INCLUDED IN BEHAVIOR)**
Is the patient experiencing hypoactive psychomotor activity that can include generalized slowing down of body movements, aimless, purposeless activity, etc.? Write your description and conclusion:
Is the patient experiencing hyperactive psychomotor activity that can include restlessness, agitation, combativeness, wringing of hands, pacing, etc.? Write your description and conclusion:
MOOD/AFFECT
Mood – is the sustained/consistent emotion that colors their perception of the word.
Is the patient’s mood sad, labile, euphoric, euthymic, expansive, anhedonic, etc.
Is the patient anxious, angry and/or depressed? Assess for mild, moderate, or severe and document findings that support your conclusion.
IMPORTANT: Ask the patient if they are having any suicidal or homicidal thoughts, if the patient indicates in any way that they, then ask them if they have a plan and report these findings to the staff immediately so measures can be taken to safeguard the patient.
Affect – Patient’s current emotional reaction that is being inferred from the patient’s facial expression.
What is the range of the patient’ affect (full or restricted)? What findings support your conclusion:
Is the patient’s affect appropriate; is the emotional expression congruent with the thought content? What findings support your conclusion:
Is the intensity of the patient’s affect blunted or flat, shallow, labile, proud, angry, fearful, anxious, guilty, etc.? What findings support your conclusion:
Does the patient have difficulty in initiating, sustaining, or terminating an emotional response? What findings support your conclusion:
DISORDERS OF THE FORM OF THOUGHT
The thought process refers to the way a person puts together ideas and associations. Is the patient disorganized, coherent, has a flight of ideas, though blocking, tangential, circumstantial, rambling, evasive? Is there a lack of cause and effect relationship and goal-directed thinking:
Thought content refers to what the person is thinking and speaking about. Does the patient have preoccupations: about illness, environmental problems, obsessions, compulsions, phobias; obsessions about suicide, homicide, hypochondriacal symptoms, and specific antisocial urges:
IMPORTANT: Ask the patient if they are having any suicidal or homicidal thoughts, if the patient indicates in any way that they, then ask them if they have a plan and report these findings to the staff immediately so measures can be taken to safeguard the patient.
Does the patient’s thought content contain delusional material? If yes, describe the types of delusion(s)? Include in your description details about the extent and nature of the delusions:
PERCEPTION
**(INCLUDED IN THOUGHT CONTENT)**
Hallucinations are a form of disturbance of the sensory system. To determine if someone is experiencing them you can the person “Have you ever heard voices or sounds that no one else can”? “Smelled something that no one else can?” “Felt like bugs were crawling all over you?” “Seen something that no one else can see?” Include in your description details about the extent and nature of the hallucination and how you reached this conclusion:
Illusions are a misperception of a person-environment such as an exit sign that looks like the devil.
COGNITION
Orientation
Person:
Place:
Time:
Is the patient’s orientation good, fair or poor; support your conclusion:
Memory functions are usually divided into remote memory, recent past memory, recent memory and immediate retention and recall.
Remote – Can the patient provide childhood data; important events: time and place of birth; various schools attended; number of children and ages and names. Is the patient’s remote memory good, fair or poor; support your conclusion:
Recent Past Memory – Can the patient tell you what they did yesterday, what did they have for breakfast, lunch, dinner? Is the patient’s recent past memory good, fair or poor; support your conclusion:
Tell the patient that you are going to ask them to repeat the three words you are going to tell them, pen, apple, watch. After the patient is finished, remind him/her that you will be asking them these in a few minutes,
Recall /Immediate Retention Memory – Ask the patient to repeat the three word you have just finished saying. Is the patient’s recent memory good, fair or poor; support your conclusion:
Recent Memory – Ask the patient to repeat the three words you told them a few minutes ago. Is the patient’s recent memory good, fair or poor; support your conclusion:
Concentration and attention is the ability to remain focused. Is the patient’s attention span good, slight, moderate or severely distractible?
Abstract/Concrete thinking is the ability to deal with concepts. Proverbs or "similarities" can determine if the patient is an abstract or concrete thinker. Ask "What do people generally mean when they say… Don't count your chickens before they're hatched?". When using similarities, ask, "In what ways are an apple and a banana alike?" Is the patient’s ability to abstract good, fair or poor; support your conclusion:
JUDGMENT AND INSIGHT
Judgment is the patient’s understanding of socially conforming behavior and the ability to understand the outcome of their behavior. If you are not aware of the patient’s judgment as what is the thing to do if you are the first person in the theatre to discover a fire and/or what will you do when you are discharged from the hospital. Is the patient’s judgment good, fair, poor; support your conclusion.
Insight is the patient’s awareness of the illness and the understanding of the outcome. Is the patient’s insight good, fair, poor; support your conclusion:
**BIOLOGICAL DATA**
Oxygenation:
Respiration: (Quality and quantity):
Temp:
B/P:
Pulse: (Quality and quantity):
Metabolism
Ingestion includes the patient's nutritional intake. How many times does he/she eat full meals or snacks per day? What do the meal and snack consist of, is the patient on a specific diet, and is the patient's report congruent with the diet limitations:
Digestion includes gas/burping, reflux, acid indigestion, nausea/vomiting, pain, ulcer, bloating, etc. Does the patient have any digestion difficulties?
Elimination includes gas/flatulence, diarrhea, loose stools, constipation, etc. How many BMs/day? Is the consistency normal? Is there any blood in the stool:
Sleep Patterns
Quality – Does the patient have difficulty falling asleep or falling back to sleep? Are they tired upon awakening? Do they have early morning awakening, bad dreams, and nightmares? Do they wet the bed, walking in sleep, etc.:
Quantity – How many hours of sleep does the patient need to feel good in the morning? How many hours of sleep do they get now? What time do you go to sleep & wake up:
**SOCIAL HISTORY**
Support system: (Is there support from family, friends, church, work, etc.):
Occupation – (Any job in the past or present, employee or volunteer; would the patient like to have a job, what would that job be):
Spiritual Assessment
What importance does religion/spirituality have in the patient’s life:
Do the patient’s beliefs help with stressful situations:
Education – What was the highest level of school completed; any vocational training programs attended; would the patient like to go back to school or vocational training:
Financial Support – who works in the household; what other means of financial support is there for the household:
Interests – What does the patient do in their spare time (e.g. watch TV; exercise; fishing; woodcraft; reading; theatre; movies; bowling; walking; running; crossword puzzles etc.):
**GraduateComprehensivePsychiatricEvaluationandPsychotherapyNoteTemplaterev.3112022copy2.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/graduatecomprehensivepsychiatricevaluationandpsychotherapynotetemplaterev-3112022copy2-docx)
**PsychiatricSOAPNoteRubric1copy2.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/psychiatricsoapnoterubric1copy2-docx)
**PsychiatricSOAPNoteRubric1copy2.docx**
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**## 3GraduateMentalStatusExamGuidecopy3.docx**
**MENTAL STATUS EXAM GUIDE**
Previous Mental Health Treatments (e g: psychopharmacology, inpatient stabilization, Occupational Therapy, Vocational Therapy, Marriage/Family Therapy, Group Therapy, Detox, ECT &/or social services):
What is the initial impression of the admitting examiner found in the initial evaluation, triage, or social worker note:
Compare your impression of the patient’s status now to the initial impression:
**BRIEF MENTAL STATUS EXAM**
Instructions; Most information can be obtained during an interaction with the patient without asking specific questions. The information must be described to support your conclusion.
GENERAL DESCRIPTION
Appearance (e.g. grooming, manner of dress, level of hygiene, facial expression, remarkable features, height, weight, nutritional status, presence of piercings, tattoos, scars, the relationship between appearance and age, etc.):
Attitude toward examiner
**(INCLUDED IN BEHAVIOR)** – Does the patient have good eye contact? Are they cooperative, friendly, attentive, interested, frank, seductive, defensive, playful, apathetic, evasive, guarded, etc.:
Speech characteristic –
What are the qualities of the patient’s speech include tone, inflection, volume, pronunciation (clear or slurred; mumbling; defects, lisp, stuttering), speed:
What is the quantity of the patient’s speech? Does the patient verbalizes freely, provide monosyllabic answers, have pressured speech, and/or are they hyperverbal:
Psychomotor activity
**(INCLUDED IN BEHAVIOR)**
Is the patient experiencing hypoactive psychomotor activity that can include generalized slowing down of body movements, aimless, purposeless activity, etc.? Write your description and conclusion:
Is the patient experiencing hyperactive psychomotor activity that can include restlessness, agitation, combativeness, wringing of hands, pacing, etc.? Write your description and conclusion:
MOOD/AFFECT
Mood – is the sustained/consistent emotion that colors their perception of the word.
Is the patient’s mood sad, labile, euphoric, euthymic, expansive, anhedonic, etc.
Is the patient anxious, angry and/or depressed? Assess for mild, moderate, or severe and document findings that support your conclusion.
IMPORTANT: Ask the patient if they are having any suicidal or homicidal thoughts, if the patient indicates in any way that they, then ask them if they have a plan and report these findings to the staff immediately so measures can be taken to safeguard the patient.
Affect – Patient’s current emotional reaction that is being inferred from the patient’s facial expression.
What is the range of the patient’ affect (full or restricted)? What findings support your conclusion:
Is the patient’s affect appropriate; is the emotional expression congruent with the thought content? What findings support your conclusion:
Is the intensity of the patient’s affect blunted or flat, shallow, labile, proud, angry, fearful, anxious, guilty, etc.? What findings support your conclusion:
Does the patient have difficulty in initiating, sustaining, or terminating an emotional response? What findings support your conclusion:
DISORDERS OF THE FORM OF THOUGHT
The thought process refers to the way a person puts together ideas and associations. Is the patient disorganized, coherent, has a flight of ideas, though blocking, tangential, circumstantial, rambling, evasive? Is there a lack of cause and effect relationship and goal-directed thinking:
Thought content refers to what the person is thinking and speaking about. Does the patient have preoccupations: about illness, environmental problems, obsessions, compulsions, phobias; obsessions about suicide, homicide, hypochondriacal symptoms, and specific antisocial urges:
IMPORTANT: Ask the patient if they are having any suicidal or homicidal thoughts, if the patient indicates in any way that they, then ask them if they have a plan and report these findings to the staff immediately so measures can be taken to safeguard the patient.
Does the patient’s thought content contain delusional material? If yes, describe the types of delusion(s)? Include in your description details about the extent and nature of the delusions:
PERCEPTION
**(INCLUDED IN THOUGHT CONTENT)**
Hallucinations are a form of disturbance of the sensory system. To determine if someone is experiencing them you can the person “Have you ever heard voices or sounds that no one else can”? “Smelled something that no one else can?” “Felt like bugs were crawling all over you?” “Seen something that no one else can see?” Include in your description details about the extent and nature of the hallucination and how you reached this conclusion:
Illusions are a misperception of a person-environment such as an exit sign that looks like the devil.
COGNITION
Orientation
Person:
Place:
Time:
Is the patient’s orientation good, fair or poor; support your conclusion:
Memory functions are usually divided into remote memory, recent past memory, recent memory and immediate retention and recall.
Remote – Can the patient provide childhood data; important events: time and place of birth; various schools attended; number of children and ages and names. Is the patient’s remote memory good, fair or poor; support your conclusion:
Recent Past Memory – Can the patient tell you what they did yesterday, what did they have for breakfast, lunch, dinner? Is the patient’s recent past memory good, fair or poor; support your conclusion:
Tell the patient that you are going to ask them to repeat the three words you are going to tell them, pen, apple, watch. After the patient is finished, remind him/her that you will be asking them these in a few minutes,
Recall /Immediate Retention Memory – Ask the patient to repeat the three word you have just finished saying. Is the patient’s recent memory good, fair or poor; support your conclusion:
Recent Memory – Ask the patient to repeat the three words you told them a few minutes ago. Is the patient’s recent memory good, fair or poor; support your conclusion:
Concentration and attention is the ability to remain focused. Is the patient’s attention span good, slight, moderate or severely distractible?
Abstract/Concrete thinking is the ability to deal with concepts. Proverbs or "similarities" can determine if the patient is an abstract or concrete thinker. Ask "What do people generally mean when they say… Don't count your chickens before they're hatched?". When using similarities, ask, "In what ways are an apple and a banana alike?" Is the patient’s ability to abstract good, fair or poor; support your conclusion:
JUDGMENT AND INSIGHT
Judgment is the patient’s understanding of socially conforming behavior and the ability to understand the outcome of their behavior. If you are not aware of the patient’s judgment as what is the thing to do if you are the first person in the theatre to discover a fire and/or what will you do when you are discharged from the hospital. Is the patient’s judgment good, fair, poor; support your conclusion.
Insight is the patient’s awareness of the illness and the understanding of the outcome. Is the patient’s insight good, fair, poor; support your conclusion:
**BIOLOGICAL DATA**
Oxygenation:
Respiration: (Quality and quantity):
Temp:
B/P:
Pulse: (Quality and quantity):
Metabolism
Ingestion includes the patient's nutritional intake. How many times does he/she eat full meals or snacks per day? What do the meal and snack consist of, is the patient on a specific diet, and is the patient's report congruent with the diet limitations:
Digestion includes gas/burping, reflux, acid indigestion, nausea/vomiting, pain, ulcer, bloating, etc. Does the patient have any digestion difficulties?
Elimination includes gas/flatulence, diarrhea, loose stools, constipation, etc. How many BMs/day? Is the consistency normal? Is there any blood in the stool:
Sleep Patterns
Quality – Does the patient have difficulty falling asleep or falling back to sleep? Are they tired upon awakening? Do they have early morning awakening, bad dreams, and nightmares? Do they wet the bed, walking in sleep, etc.:
Quantity – How many hours of sleep does the patient need to feel good in the morning? How many hours of sleep do they get now? What time do you go to sleep & wake up:
**SOCIAL HISTORY**
Support system: (Is there support from family, friends, church, work, etc.):
Occupation – (Any job in the past or present, employee or volunteer; would the patient like to have a job, what would that job be):
Spiritual Assessment
What importance does religion/spirituality have in the patient’s life:
Do the patient’s beliefs help with stressful situations:
Education – What was the highest level of school completed; any vocational training programs attended; would the patient like to go back to school or vocational training:
Financial Support – who works in the household; what other means of financial support is there for the household:
Interests – What does the patient do in their spare time (e.g. watch TV; exercise; fishing; woodcraft; reading; theatre; movies; bowling; walking; running; crossword puzzles etc.):
**GraduateComprehensivePsychiatricEvaluationandPsychotherapyNoteTemplaterev.3112022copy2.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/graduatecomprehensivepsychiatricevaluationandpsychotherapynotetemplaterev-3112022copy2-docx)
**PsychiatricSOAPNoteRubric1copy2.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/psychiatricsoapnoterubric1copy2-docx)
**## 3GraduateMentalStatusExamGuidecopy3.docx**
**MENTAL STATUS EXAM GUIDE**
Previous Mental Health Treatments (e g: psychopharmacology, inpatient stabilization, Occupational Therapy, Vocational Therapy, Marriage/Family Therapy, Group Therapy, Detox, ECT &/or social services):
What is the initial impression of the admitting examiner found in the initial evaluation, triage, or social worker note:
Compare your impression of the patient’s status now to the initial impression:
**BRIEF MENTAL STATUS EXAM**
Instructions; Most information can be obtained during an interaction with the patient without asking specific questions. The information must be described to support your conclusion.
GENERAL DESCRIPTION
Appearance (e.g. grooming, manner of dress, level of hygiene, facial expression, remarkable features, height, weight, nutritional status, presence of piercings, tattoos, scars, the relationship between appearance and age, etc.):
Attitude toward examiner
**(INCLUDED IN BEHAVIOR)** – Does the patient have good eye contact? Are they cooperative, friendly, attentive, interested, frank, seductive, defensive, playful, apathetic, evasive, guarded, etc.:
Speech characteristic –
What are the qualities of the patient’s speech include tone, inflection, volume, pronunciation (clear or slurred; mumbling; defects, lisp, stuttering), speed:
What is the quantity of the patient’s speech? Does the patient verbalizes freely, provide monosyllabic answers, have pressured speech, and/or are they hyperverbal:
Psychomotor activity
**(INCLUDED IN BEHAVIOR)**
Is the patient experiencing hypoactive psychomotor activity that can include generalized slowing down of body movements, aimless, purposeless activity, etc.? Write your description and conclusion:
Is the patient experiencing hyperactive psychomotor activity that can include restlessness, agitation, combativeness, wringing of hands, pacing, etc.? Write your description and conclusion:
MOOD/AFFECT
Mood – is the sustained/consistent emotion that colors their perception of the word.
Is the patient’s mood sad, labile, euphoric, euthymic, expansive, anhedonic, etc.
Is the patient anxious, angry and/or depressed? Assess for mild, moderate, or severe and document findings that support your conclusion.
IMPORTANT: Ask the patient if they are having any suicidal or homicidal thoughts, if the patient indicates in any way that they, then ask them if they have a plan and report these findings to the staff immediately so measures can be taken to safeguard the patient.
Affect – Patient’s current emotional reaction that is being inferred from the patient’s facial expression.
What is the range of the patient’ affect (full or restricted)? What findings support your conclusion:
Is the patient’s affect appropriate; is the emotional expression congruent with the thought content? What findings support your conclusion:
Is the intensity of the patient’s affect blunted or flat, shallow, labile, proud, angry, fearful, anxious, guilty, etc.? What findings support your conclusion:
Does the patient have difficulty in initiating, sustaining, or terminating an emotional response? What findings support your conclusion:
DISORDERS OF THE FORM OF THOUGHT
The thought process refers to the way a person puts together ideas and associations. Is the patient disorganized, coherent, has a flight of ideas, though blocking, tangential, circumstantial, rambling, evasive? Is there a lack of cause and effect relationship and goal-directed thinking:
Thought content refers to what the person is thinking and speaking about. Does the patient have preoccupations: about illness, environmental problems, obsessions, compulsions, phobias; obsessions about suicide, homicide, hypochondriacal symptoms, and specific antisocial urges:
IMPORTANT: Ask the patient if they are having any suicidal or homicidal thoughts, if the patient indicates in any way that they, then ask them if they have a plan and report these findings to the staff immediately so measures can be taken to safeguard the patient.
Does the patient’s thought content contain delusional material? If yes, describe the types of delusion(s)? Include in your description details about the extent and nature of the delusions:
PERCEPTION
**(INCLUDED IN THOUGHT CONTENT)**
Hallucinations are a form of disturbance of the sensory system. To determine if someone is experiencing them you can the person “Have you ever heard voices or sounds that no one else can”? “Smelled something that no one else can?” “Felt like bugs were crawling all over you?” “Seen something that no one else can see?” Include in your description details about the extent and nature of the hallucination and how you reached this conclusion:
Illusions are a misperception of a person-environment such as an exit sign that looks like the devil.
COGNITION
Orientation
Person:
Place:
Time:
Is the patient’s orientation good, fair or poor; support your conclusion:
Memory functions are usually divided into remote memory, recent past memory, recent memory and immediate retention and recall.
Remote – Can the patient provide childhood data; important events: time and place of birth; various schools attended; number of children and ages and names. Is the patient’s remote memory good, fair or poor; support your conclusion:
Recent Past Memory – Can the patient tell you what they did yesterday, what did they have for breakfast, lunch, dinner? Is the patient’s recent past memory good, fair or poor; support your conclusion:
Tell the patient that you are going to ask them to repeat the three words you are going to tell them, pen, apple, watch. After the patient is finished, remind him/her that you will be asking them these in a few minutes,
Recall /Immediate Retention Memory – Ask the patient to repeat the three word you have just finished saying. Is the patient’s recent memory good, fair or poor; support your conclusion:
Recent Memory – Ask the patient to repeat the three words you told them a few minutes ago. Is the patient’s recent memory good, fair or poor; support your conclusion:
Concentration and attention is the ability to remain focused. Is the patient’s attention span good, slight, moderate or severely distractible?
Abstract/Concrete thinking is the ability to deal with concepts. Proverbs or "similarities" can determine if the patient is an abstract or concrete thinker. Ask "What do people generally mean when they say… Don't count your chickens before they're hatched?". When using similarities, ask, "In what ways are an apple and a banana alike?" Is the patient’s ability to abstract good, fair or poor; support your conclusion:
JUDGMENT AND INSIGHT
Judgment is the patient’s understanding of socially conforming behavior and the ability to understand the outcome of their behavior. If you are not aware of the patient’s judgment as what is the thing to do if you are the first person in the theatre to discover a fire and/or what will you do when you are discharged from the hospital. Is the patient’s judgment good, fair, poor; support your conclusion.
Insight is the patient’s awareness of the illness and the understanding of the outcome. Is the patient’s insight good, fair, poor; support your conclusion:
**BIOLOGICAL DATA**
Oxygenation:
Respiration: (Quality and quantity):
Temp:
B/P:
Pulse: (Quality and quantity):
Metabolism
Ingestion includes the patient's nutritional intake. How many times does he/she eat full meals or snacks per day? What do the meal and snack consist of, is the patient on a specific diet, and is the patient's report congruent with the diet limitations:
Digestion includes gas/burping, reflux, acid indigestion, nausea/vomiting, pain, ulcer, bloating, etc. Does the patient have any digestion difficulties?
Elimination includes gas/flatulence, diarrhea, loose stools, constipation, etc. How many BMs/day? Is the consistency normal? Is there any blood in the stool:
Sleep Patterns
Quality – Does the patient have difficulty falling asleep or falling back to sleep? Are they tired upon awakening? Do they have early morning awakening, bad dreams, and nightmares? Do they wet the bed, walking in sleep, etc.:
Quantity – How many hours of sleep does the patient need to feel good in the morning? How many hours of sleep do they get now? What time do you go to sleep & wake up:
**SOCIAL HISTORY**
Support system: (Is there support from family, friends, church, work, etc.):
Occupation – (Any job in the past or present, employee or volunteer; would the patient like to have a job, what would that job be):
Spiritual Assessment
What importance does religion/spirituality have in the patient’s life:
Do the patient’s beliefs help with stressful situations:
Education – What was the highest level of school completed; any vocational training programs attended; would the patient like to go back to school or vocational training:
Financial Support – who works in the household; what other means of financial support is there for the household:
Interests – What does the patient do in their spare time (e.g. watch TV; exercise; fishing; woodcraft; reading; theatre; movies; bowling; walking; running; crossword puzzles etc.):
**GraduateComprehensivePsychiatricEvaluationandPsychotherapyNoteTemplaterev.3112022copy2.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/graduatecomprehensivepsychiatricevaluationandpsychotherapynotetemplaterev-3112022copy2-docx)
**PsychiatricSOAPNoteRubric1copy2.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/psychiatricsoapnoterubric1copy2-docx)