clinical write up - for seek the geek only

The Clinical Write Up

Note: This outline may vary from practice to practice. However, the content domains included in this sample format are to be considered ‘industry standard’ for the clinical interview. The entire write up must be two pages or less. For the purposes of this class, anything longer than two pages earns no credit. The clinical write up needs to be in this specific format.

Identifying Data: (ID) Age, gender, ethnicity, other clinically relevant demographic data, how referred, how arrived, and/or the setting (outpatient clinic, emergency room, jail, ect). This part is one to three lines at most. Keep in mind cultural considerations.

Chief Complaint: (CC) Brief synopsis of reason for presentation and who is making the complaint. Use a quote from the patient/client; document it in quotation marks, e.g. “I’ve been so sad lately.” This part is typically one line.

History of Presenting Illness: (HPI) Symptom list, onset/precipitant (eg. “since learning of her terminal cancer diagnosis…”), duration, and progression. How it effects his/her functioning (relationships, home, work, school, friends, usual activities, etc.) and if it is causing the client distress. Efforts to compensate (substance use, distraction techniques, and any coping skills). Include any statements and situational evidence of risk. This part is probably a quarter to a third of a page. Include what the patient/client reports or denies.

Social History: (SH) Living situation: marriage, divorced, widowed, occupation, children, school, military status, ect. This part is typically one to five lines long.

Substance History: (SAHx) History of all substances of potential use and abuse. Treatment hx of substance use. Any recent changes in substance use. This part is typically one to five lines long.

Psychiatric History: (PH) History of all contact with counselors, therapists, psychologists, psychiatrists, clinics, ect. If the client/patient is on any psychiatric medications, list them in this section. Also include any hospitalizations for mental health. This part is typically one to five lines long.

Family History: (FH) Family history of mental health issues, diagnoses, and treatments (include if relatives are on psychiatric medication). Mental health conditions that run in families. This part is typically one to three lines long.

Medical History: (MH) History of medical illness, injury, etc. Include any treatments or current medication the client/patient is taking. Also note current medical symptoms, side effects of medication, or conditions that effect mental health or behavior. In this section you can also note any allergies, or illnesses that run in his or her family. Also include in this section the last time the client had a physical. This part is typically one to four lines long.

Mental Status Examination (MSE): THIS is the nuts and bolts of the psychiatric evaluation. See Mental Status Exam Outline, and write this section in the order listed on the handout. Observational evidence of risk is there? This, along with HPI, is the only other lengthy section. It might be a quarter to a third of a page long.

Formulation: (Form) or (Assess) WHAT is going on, and WHY is it going on? What is your clinical assessment of the level of risk? This part is typically two to five lines long, stating what is happening, why and the risk.

Diagnosis: (DX) List all diagnoses and any relevant v codes using the DSM 5.

Plan: What do you recommend? Who will implement this plan? Level of care? Consider safety, medical condition, cognitive status, psychotherapy, medications. Do not forgot to rule out medical. This part is typically two to five lines long.

Mental Status Exam Outline

Mental Status :

Appearance

Behavior

Speech (tone, rate, volume)

Mood (subjective)

Affect (objective)

Cognitive Fx

(Level of Consciousness, Orientation, Concentration, Memory,

Intelligence, see Folstein Mini-Mental Status Exam).

Perceptions

(Hallucinations, derealization, depersonalization)

Thought Disorder (psychosis)

(Production, Possession, Content, Form)

(Keep in mind: some thought disorders are detected by changes in the way the patient speaks, which means we should stay aware for the potential for the possibility of the presence of problems unique to speech production (i.e. tumors, dementia, etc.)

**Rule Out Medical** Ask the client/patient when is the last time they have had a physical or visited their physician.

· Disorders of the Production or Stream of Thought

· In this category there is an alteration in either the amount or speed of thought.

· Pressure of thought: An increase in the amount of spontaneous speech compared to what is considered customary. Common in mania or schizophrenia.

· Poverty of thought: When the client/patient has only a few thoughts, which lack variety and richness, and seem to move through the mind slowly. Common in depression or schizophrenia.

· Thought blocking: A condition where a thought is partially expressed but not completed.

· Disorders of the Possession of Thought

· Thought insertion: The belief that someone else is inserting thoughts into my mind.

· Thought withdrawal: The belief that someone else is taking thoughts from my mind.

· Thought broadcasting: The belief that I can send my thoughts into the minds of others.

· Disorders of the Content or Meaning of Thought

· Delusions: Fixed beliefs that are not based in reality and that the person refuses to give up, even when presented with factual information. Can be mood congruent or incongruent.

· Ideas of Reference (referential thinking): The belief that external communications such as the radio or TV are referring to me.

· Ideas of Influence: The belief that unrelated actions or events or conditions are influencing each other (magical thinking, for example).

· Verbigeration: Sounds, words or phrases are repeated in a senseless way. It is a type of stereotypy.

· Neologisms: New word formations. e.g. "I got so angry I picked up a dish and threw it at the gesplinker."

· Echolalia: Echoing of one's or other people's speech

· Disorders of the Form, or Structure of Associations, of Thought.

· Perseveration: Persistent repetition of words or ideas. (see in dementia also)

· Derailment: Ideas slip off the track on to another which is obliquely related or unrelated. The associations are generally apparent to the listener.

· Concrete Thinking: The client/patient is unable to form abstract associations. Questions are interpreted in their most concrete form. “So, what brings you to the office today?” “A car.”

· Loosening of Associations:

· Circumstantial: Speech that is very delayed at reaching its goal, citing many unnecessary details along the way. The associations are generally apparent to the listener.

· Tangential: Speaking in an oblique, tangential or irrelevant manner, venturing off onto related but unnecessary topics, often not returning to the original goal. The associations are generally apparent to the listener.

· Flight of Ideas: Similar to tangential in that there are numerous changes of topic, yet there is a more rapid and pressured quality to the switching, and the associations are looser, harder to apprehend for the listener. The initial goal of the statement is lost.

· Word Salad: Speech that is unintelligible because, though the individual words are real words, the manner in which they are strung together results in incoherent gibberish.

Judgment: Can the client/patient make reasonable and safe decisions.

Insight: Degree of awareness of condition and how it effects his or her functioning.

Risk: Ideation, Plan, Intent, Access/Feasibility, and Rescue Factor.

Folstein Mini-Mental Status Exam (maximum score = 30)

ORIENTATION TO TIME (1 pt each)

__ What year is this? __ What season is this? __ What month is this? __ What is today’s date? __ What day of the week is it?

ORIENTATION TO PLACE (1 pt each)

__ Which state are we in? __ Which county are we in? __ Which city are we in? __ Which hospital are we in? __ Which floor are we on?

IMMEDIATE RECALL (3)

__ Name three objects and ask the patient to repeat all three objects. Repeat the three objects until the patient learns them all. Count the number of times it take the patient to learn the objects.

ATTENTION (either test) (5)

__ Serial 7’s: subtract 7 from 100, then subtract 7 from the answer you get and keep subtracting 7 until I tell you to stop. Alternatively, spell the word “world” backwards.

DELAYED RECALL (3) __ What are the three words I asked you to remember earlier?

NAMING (2) __ Show patient common objects (ie. watch and pen) and ask the patient to name them.

REPETITION (1) __ Have the patient repeat the following sentence exactly: “No ifs, ands, or buts.”

3 STAGE COMMAND (3) ___ Have the patient listen first and then follow these directions when you are finished:

“Take this piece of paper in your right hand, use both hands to fold it in half, and then put it on the floor.”

READING (1) __ Write this command and tell the patient to read and follow it: "Close your eyes."

COPYING (1) __ Give the patient a clean sheet of paper and ask him/her to copy the design (interlocking pentagons)

WRITING (1) __ On same sheet of paper, ask the patient to write a complete sentence. The sentence must have acceptable grammatical structure, with a noun and verb.

**A score of 24 or less indicates increased potential for cognitive disorder and indicates possible need for more detailed medical evaluation

Common Abbreviations in Clinical Psych Documents

2 due to

 (delta) refers to a change. Ex: “No in sleep” means “No change in sleep”

a before

A&Ox3 Alert and Oriented times 3 (person, place, and time)

Assess: Assessment section of the clinical assessment document

c with

CC: Chief Complaint section of the clinical assessment document

cc chief complaint

Ct client/patient

cx cancel

DFA difficulty falling asleep

dx diagnosis

DX: Diagnosis section of the clinical assessment document

du during

EMA early morning awakening

ER emergency room

Form: Formulation section of the clinical assessment document

FRT faulty referential thinking

fx function

HI homicidal ideation

HPI: History of Presenting Illness section of the clinical assessment document

hx history

I/P inpatient

ID: Identifying Data section of the clinical assessment document

LOA loosening of associations

LOC level of consciousness

LTM long term memory

MH: Medical history section of the clinical assessment document

MMSE: Mini Mental State Exam (Folstein)

ms mental status

MSE: Mental Status Exam

NR& V normal rate and volume

O/P outpatient

p after

PPH: Past Psych History section of the clinical assessment document

Pt patient

Rx prescribed medication, prescription

s without

SA: Substance Abuse History section of the clinical assessment document

SCD sleep continuity disturbance

SH: Social History section of the clinical assessment document

SI suicidal ideation

STM short term memory

sx symptom

sx 12 section 12 of Mass State General Law

tx treatment

wnl within normal limits (not we never looked)

Definitions

Disorder: Condition in which there is a disturbance in normal functioning or reported subjective sense of elevated distress.

Sign: Objective evidence of disease or disorder that can be observed by evaluator (i.e. bizarre behavior indicative of psychosis, pacing, fidgeting, ect.).

Symptom: Subjective report of a sign or indication of something else (i.e. report of chest pain indicating heart attack, or report of apathy indicating depression), often noted to be a change from normal function, sensation, or appearance. (this is what the client/patient reports to the clinician).

Syndrome: A syndrome, by medical definition, is a cluster of symptoms (made up of signs and symptoms) occurring together, that characterize a specific disease.