mental status

Patient Name:

Admission Date:

Patient Age and Unit Admitted to:

Patient’s Reason for Admission/ Chief Complaint:

Co-morbid Conditions:

Mental Status Examination

What You See (list)

Descriptive example (narrative)

1. Appearance (observed)

· Grooming/Clothing

· Hygiene

· Posture

· Gait

· Obese/average or normal/ underweight

· Evidence of scars/ abrasions/ bruises/ tattoos/ or other physical markings

2. Behavior (observed)

· Mannerisms

· Gestures

· Eye contact

· Psychomotor activity (ex. retardation or agitation)

· Movements: tremor/ tics/ abnormal movements

· Possible descriptors: agitated, restless, easily distracted, hyperactive, hypoactive, lethargic, catatonic, wavy flexibility, echopraxia, akathisia

3. Attitude (observed)

· Ability to follow commands

· Ability to provide reliable information.

· Possible descriptors: cooperative, hostile, open, secretive, evasive, suspicious, apathetic, focused, defensive, defiant, oppositional, withdrawn, aggressive, reliable reporter/good historian

4. Cognition (observed/inquired)

· Level of Consciousness

· Orientation

· Attention

· Concentration

· Memory (immediate, recent, remote)

· Abstract vs. concrete cognition

5. Speech and Language (observed)

· Content of speech

· Rate

· Volume

· Tone and Rhythm

6. Mood and Affect (inquired/observed)

Mood

· How the patient describes what they are feeling

· Possible descriptors include:

· Labile, sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable

Affect

· How the client outwardly is expressing emotion

· Appropriateness to situation

· Congruency with mood

· Congruency with thought

· Other descriptors include:

· Broad, restricted, constricted, blunted, flat, normal intensity, appropriate, incongruent, anxious, animate

7. Thought Disturbance (inquired/observed)

Process

· Describes the rate of thoughts, how they flow and are connected

· Possible descriptors: Linear, goal-directed, circumstantial, tangential, loose associations, incoherent, evasive, racing, blocking, perseveration, neologisms.

Content and/or perceptual disturbances:

· Refers to the themes that occupy the patient’s thoughts and perceptual disturbances

· Possible descriptors: preoccupations, illusions, ideas of reference, hallucinations, derealization, depersonalization, delusions, obsessions, suicidal/homicidal ideation, rumination

8. Judgment and Insight (Inquired/Observed):

Judgment

· Good, fair, or poor

· Impulse control

Insight

· Good, fair, partial, poor

Adaptive Coping Strategies vs Defense Mechanisms

Possible defense mechanisms:

Denial, projection, rationalization, sublimation, undoing, displacement, intellectualization, avoidance, repression, suppression

9. Safety of Self/ Others

Risk of Self/Suicidal/Self-Injury

· Fully assessed-no indicators of risk

· If yes then

· Suicidal ideation (current, past)

· Suicide attempts (hx of)

· Plans to attempt (current, past)

· Access to means

· Family history

· Non-suicidal self-injury (cutting, scratching, or other self-mutilation) present?

· Unintentional (when delusions, demented, intoxicated, in manic stages) present?

Harm to Others/Aggression

· Fully assessed- no indication of risk identified

· If yes then

· Plan (current, past) to assault

Property Destruction

· Fully assessed- no indication of risk identified

· If yes then

· Current admission

· Hx of