Nursing HOMEWORK 10
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Interactive Mental Status Exam Assessment Charting |
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Subjective (what the client stated): …as perceived by the client |
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How feeling? Click or tap here to enter text. How medications working? Click or tap here to enter text. How sleeping? Click or tap here to enter text. (hrs/night) Complaints or concerns? Click or tap here to enter text. How eating? Click or tap here to enter text. Symptoms reported by the client? Click or tap here to enter text.
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Objective (what you observed): |
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Demographic (Historical, background supplied upon intake) |
Observed (Discerned while interacting w/client.) |
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Demographic information: Name/initials/identifiers Click or tap here to enter text. Age : Click or tap here to enter text. Gender: Choose an item. Location: Click or tap here to enter text. Mental health history: Past diagnoses and treatment (for all mental health issues). Click or tap here to enter text. Psychiatric drugs currently taken. Note: 1. Any side effects 2. Complications 3. Contraindications 4. Current effectiveness Click or tap here to enter text.
Substance abuse history: Current and past drug and alcohol use. Note: 1. Substance 2. Route 3. Frequency 4. Last use 5. Date quit Click or tap here to enter text. |
Medical history: Major surgeries, head injuries, chronic illnesses and major accidents. Click or tap here to enter text.
List current non-psychiatric medications (prescription and over-the-counter). Click or tap here to enter text.
Socio-Economic History: Any personal information that can provide insight into the client's presenting problem. (Client's financial and employment status, family background, marital status, sexual orientation, immediate family, cultural and religious background, criminal history) Click or tap here to enter text.
Support System: Client’s listed support system Click or tap here to enter text. Concerns or noted recommendations Click or tap here to enter text. Referrals/leads to follow up Click or tap here to enter text. |
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Appearance : Choose an item.
Attitude: Choose an item.
Attitude toward examiner : Choose an item.
ADLs (Ability to care for self) Choose an item.
Compliance : Cooperation with staff or others: Choose an item.
General behavior: Choose an item.
Client's strengths and weaknesses: Strengths: Personal and outside factors that could make completion of treatment more likely or successful. May be his or her desire to work on presenting problem and/or having a support system in place. Click or tap here to enter text.
Weaknesses : Past mental health and medical issues as well as financial problems that could make completion of treatment difficult. Click or tap here to enter text.
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LOC: Choose an item.
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Assessment (contents of your mental status exam) |
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General Assessment & Motor Behavior: Vital Signs (if indicated): T Click or tap here to enter text. BP Click or tap here to enter text. HR Click or tap here to enter text. R Click or tap here to enter text.
Appearanc e: Choose an item. Communication : Choose an item. LOC: Choose an item. Psychomotor Activity: Choose an item. Behaviors: Choose an item.
Mood and Affect: Mood: overall pervasive emotional state Choose an item. Affect: current observable emotion expression Choose an item.
Thought Process and Content: Thought Process (POT)- How client is thinking ( Inferred from speech and speech patterns) Choose an item.
Content of Thought (COT)- What client is thinking? Assess by: Determine if what the client says makes sense. Are ideas related and do they flow logically from one to the next? Are there any dysfunctions in thought process and content noted? Choose an item.
Self-harm or suicidal ideation Choose an item. Lethality assessment completed: Choose an item. Duty to warn: (indication of need) Choose an item. If yes, who Click or tap here to enter text.
Sensorium and Intellectual Processes: Orientation: Person Choose an item. Place Choose an item. Time Choose an item. Situation Choose an item.
Memory: Assess by: Ask questions with verifiable answers to directly assess recent and remote memory . Recent Memory? Choose an item. Remote Memory? Choose an item.
Ability to concentrate : Assess by: Have client spell a word backwards, days of the week backwards, Serial sevens (from 100 subtract 7, then 7 again), Perform a three-part task. Ability to concentrate? Choose an item.
Abstract Thinking: Assess by: Interpret a proverb. Capable of abstract thought? Choose an item. |
Judgment and Insight: Judgement- ability to interpret one’s environment and situation correctly and adapt behavior and decisions accordingly . Does client show a lack reasonable care for self or others? Engage in risky behaviors? Exercise regular poor decision making as evidenced by the outcomes of recent life choices? Choose an item. Assess by: Ask client hypothetical questions putting them in a situation where they must decide what they would do and then determine if their response is sound and reasonable. What is client’s level of judgement? Choose an item.
Insight- ability to understand the true nature of one’s |
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situation and accept some personal responsibly for it. Does client blame others for problems or circumstances? Not accept responsibility for behavior or actions? Believe problems can be solved with little or no personal effort? Choose an item. Can be inferred from: the client’s ability to realistically describe the strengths and weakness of his or her behavior. What is client’s level of insight? Choose an item.
Self-Concept: Self-concept- the way one views self in terms of personal worth and dignity (includes physical self, personal qualities and attributes). Assess by: Ask client to describe self and what characteristics are liked and what would like to be changed (this denotes body image). Client’s self-concept : Choose an item. Emotional spectrum : What emotions does the client frequently experience? Choose an item. Is the client comfortable with those emotions? Choose an item.
Coping strategies: How does the client cope with problems, anger, and disappointments? Assess by: Ask client directly, “What do you do to manage those specific situations?” Note client statement: Click or tap here to enter text. How well does the strategy work for them? Choose an item.
Roles and Relationships: Roles - Determine client’s level of satisfaction with the roles they perceive themselves in and whether client feels they adequately fulfill those roles. Roles client identifies: Click or tap here to enter text. Client satisfaction with roles: Click or tap here to enter text. Does client feel they fulfill those roles? Choose an item. Relationships : Determine client’s satisfaction with any relationships they perceive themselves to be involved in and any loss of relationships. Assess by: Determine client’s area of concern and level of need. Relationships client identifies: Click or tap here to enter text. Client satisfaction with relationships: Click or tap here to enter text.
Physiologic and Self-Care Considerations: Eating and sleeping problems : Assess by: Determine if the psychological issue has altered the physiological areas of nutrition and rest. Sleep pattern: Choose an item. Nutritional status: Choose an item. General health problems: (Risk assessment) Assess by: Determine if client has any other health issues that “would affect” their psychological condition. *Are they taking any medications? Are they compliant with that medication? Do they follow dietary recommendations? Do they use alcohol, OTC or illicit drugs? Summary of any relevant general health problems:Click or tap here to enter text.
Activities of daily living: ADLs (Ability to care for self) Choose an item. Compliance : Previous treatment plans: Choose an item. Medication: Choose an item. Cooperation with staff or others: Choose an item. |
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Abnormal Sensory Experiences or Misperceptions : Hallucinations - false sensory perceptions not existing in reality include one of five senses. Client hears, sees, tastes, feels or smells something that is not there (Command hallucinations most dangerous). Does client endorse hallucinations? Choose an item. If yes, what? Click or tap here to enter text.
Delusion- fixed false belief. Client believes something (a story, idea, perception) not based in reality. Does client endorse delusions?Choose an item. If yes, what? Click or tap here to enter text.
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Plan (Your recommendations based on the above): |
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Goals and outcomes (What would be a measurable positive result for this client?) Click or tap here to enter text.
Interventions (What will you do to meet the goals and outcomes?) Click or tap here to enter text.
Measure and evaluation method (Determine a way to measure/evaluate if the outcome was met by your purposed interventions.) Click or tap here to enter text.
Teaching (What teaching would be essential to this impart on this client?) Click or tap here to enter text.
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Additional Assessment Data (Any Area) |
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Click or tap here to enter text. |
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Narrative Nursing Documentation
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Time |
Signed narrative documentation of problems with interventions and patient response |
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Instructor Comments: Click or tap here to enter text.