Mental Status Exam Template 1

D MENTAL STATUS ASSESSMENT:Mental Health Examination include these four main sections: Appearance (5 points), Behavior (5 points), Cognition (5 points) and Thought Processes (5 points) (A, B, C, T). Mental Status Examinations are important to complete when patients have abnormal affects or behaviors in certain situations. Must complete all sections with resource tools attached to form to identify your ratings for depression, anxiety, suicidal tendencies, mood and cognitive issues. -----------------APPEARANCE AND BEHAVIOR:(Attach depression scale.)  Agitated cooperative and reasonable   disheveled  grooming appropriate  psychomotor retardation  hostile/threatening  unusual/bizarre Rationale for Findings: Dominic knows that he is depressed and needs medical attention. He feel like a burden to his wife and children. He is alert and oriented despite his diagnosis/ condition. He has had bizarre/ unusual behaviors such as walking in a public place shouting and singing along with skipping. He wants to get the help that is needed to ensure he is alive to watch his children grow. ORIENTATION AND CONSCIOUSNESS: (Attach mini mental exam) alert and attentive   lethargic  obtunded oriented x3   disoriented to place  disoriented to time Rationale for Findings: Dominic knows what is happening around him and is coherent/ aware of the fact that he has mental health problems. He is cooperative with the treatment that the doctor has recommended for him and is able to think for himself/ is not cognitively impaired despite his condition. SPEECH: normal rate/rhythm   dysarthric  increased latency of response  mute  poverty of speech  pressured/pushed speech  slow  Slurred Rationale for Findings: Dominic can hold a stable and relatively calm/ composed conversation. He speaks clearly and coherently. LANGUAGE: intact   expressive aphasia  partially aphasic  receptive aphasia Student Name: _____________________________________________________________ Patient initials: ______________________________________________________________ Diagnosis: _________________________________________________________________ Other: ____________________________________________________________________________ Rationale for Findings: Dominic doesn’t jumble his words or sentences/ or say thing that don’t make sense. He speaks with coherence and is a ble to determine what others are saying to him and what context is being used when being spoken to. He is able to verbally respond appropriately and clearly. MOOD AND AFFECT: (Attach Mood Questionnaire)  mood euthymic  affect is congruent with mood  affect blunted/restricted/constricted affect flat  affect inappropriate  affect labile  affect is wide range  mood angry   mood anxious  mood dysphoric  mood euphoric  mood depressed Rationale for Findings: Dominic is severely depressed, angry with himself, and has anxiety. He is not aggressive towards others. He feels like a burden to his family and friends. He is aware that he is depressed but is self-aware about what needs to be done to ensure he gets the help he needs to get better. PERCEPTUAL DISTURBANCE (hallucinations, illusions): none   auditory hallucinations at baseline for patient  auditory hallucinations  auditory command hallucinations  auditory command hallucinations for self/other harm, contracts for safety  olfactory hallucinations  tactile hallucinations  visual hallucinations  illusions Other: ______________________________________________ Rationale for Findings: Dominic states that he has a “murderous voice in his head that is trying to kill him”. He knows that he needs/wants to be there for his family and able to watch them grow but he feels like he doesn’t deserve to live. THOUGHT PROCESS AND ASSOCIATION: (Attach anxiety scale) normal, coherent   loosening of associations  blocking  circumstantial  clanging  disorganized Student Name: _____________________________________________________________ Patient initials: ______________________________________________________________ Diagnosis: _________________________________________________________________  flight of ideas  ideas of reference  illogical  neologisms  perseveration  obsessive  tangential Rationale for Findings: THOUGHT CONTENT (delusions, obsessions etc.): no unusual thought content   delusions  depersonalization  obsessions Rationale for Findings: Dominic states that he has “dreams” where he is trapped in the mental facility and is held against his will for the rest of his life and that he is afraid that it will happen. He states that he doesn’t belong there. SUICIDAL OR VIOLENT IDEATION: (Attach Suicidal Severity Scale) none   suicidal ideation passive without plan, contracts for safety  suicidal ideation active with plan, contracts for safety  suicidal ideation active with plan, will not contract for safety  passive/nonspecific homicidal ideation, contracts for safety  no potential target/victim identifiable  homicidal ideation, contracts for safety,  potential target/victim identifiable Other: _______________________________________________________________ Rationale for Findings: He has tried to commit suicide/ self-harm by overdosing on pills/alcohol on three separate occasions and is has admitted himself to the mental facility because he was afraid that he would attempt it agan. He is cooperative with treatment plans given to him. INSIGHT: good   limited  None Rationale for Findings: Dominic is understanding that there is a problem and has made decisions on his own to try to get the help that he needs to help his condition. JUDGMENT: (Attach anxiety Scale) good   impulsive  impaired  severely impaired Rationale for Findings: The judgement Dominic makes on the quality of his life is impaired. He feels as though he is a burden to his family and doesn’t see the need to be alive. MEMORY: (Attach Dementia Scale if applicable). Student Name: _____________________________________________________________ Patient initials: ______________________________________________________________ Diagnosis: _________________________________________________________________  intact  impaired recent  impaired remote Rationale for Findings: His memory isn’t impaired. FUND OF KNOWLEDGE: The Client’s General Intellectual Level / Basic Knowledge  Above average  Average  Below average Rationale for Findings: Dominic is aware of what is going on around him, he can do normal daily activities. He has an education and his knowledge on current events etc. isn’t impaired. He is oriented and coherent. MENTAL STATUS NARRATIVE NOTES: Dominic was originally diagnosed with bipolar disorder, but he was re-evaluated and was given different tools and medication regimen to help him cope with his depression and suicidal thoughts and attempts. He has impaired judgement to a certain extent but is oriented and alert considering his mental state/ condition. It appears he was hearing a voice telling him to harm himself. He is cooperative and responsive to the treatments that were recommended and given to him For Normal Range of Findings/Abnormal Findings, please refer to your Jarvis Textbook on page 63-82. Make sure you attach these resource tools to your Mental Health Assessment to measure your patients’ mood, depression, cognitive and anxiety:       Geriatric Depression Scale or the Hamilton Rating Scale for Depression Mini Mental Exam Mood Disorder Questionnaire Functional Dementia Scale Hamilton Anxiety Rating Scale or the Beck Anxiety Inventory Columbia Suicide Severity Rating (C-SSRS-Risk Assessment)