how to report patient affect mental status

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The following two fictional reports are samples of psychiatric-oriented MSEs. These sample reports can be helpful if you’re learning to conduct Mental Status Examinations and write MSE reports. They’re excerpted from the text, Clinical Interviewing (6th edition; 2017, John Wiley & Sons).

Are there any sample reports of psychiatric-oriented mental status examinations?

A mental status evaluation is a necessary part of any client assessment no matter what the presenting problem. It should be documented in the record either in list form or in narrative form. This article illustrates both the list and the narrative.

What is a mental status evaluation and how is it documented?

The clinician who has in mind the components of the mental status can likely assess a client in the first interview. This will contribute essential information to the initial evaluation and makes possible the development of goals and treatment plans very early in the contact. Retiring?

How to assess a client for mental health?

My belief is that understanding an individual’s mental status can be a useful process. It’s especially useful when MSEs are conducted collaboratively. . . which is what I recommend. Third, you’re correct in that it’s often difficult to discern the difference between auditory hallucinations and other experiences, particularly religious ones.

Is it possible to understand an individual’s mental status?

How do I write a mental status report?

A good report is brief, clear, concise, and addresses the areas below:Appearance.Behavior/psychomotor activity.Attitude toward examiner (interviewer)Affect and mood.Speech and thought.Perceptual disturbances.Orientation and consciousness.Memory and intelligence.More items...•

How do you assess the mental status of a patient?

Assessment of the patient with altered mental status must include the following key elements:Level of consciousness. Is the patient aware of his surroundings?Attention. ... Memory. ... Cognitive ability. ... Affect and mood. ... Probable cause of the present condition.

How do you assess patient affect?

Affect is a patient's moment to moment expression. This is assessed through posture, movements, body, facial expressions and tone of voice. You do not ask any questions in this section; it's purely observational.

How do you describe affect?

Examples of descriptors for affect include sad, depressed, anxious, agitated, irritable, angry, elated, expansive, labile, inappropriate, incongruent with content of speech. SPEECH AND LANGUAGE. Descriptions of speech should relate to the mechanics and tempo of articulation.

How do you document mental status in nursing?

A normal level of orientation is typically documented as, “Patient is alert and oriented to person, place, and time,” or by the shortened phrase, “Alert and oriented x 3.” If a patient is confused, an example of documentation is, “Patient is alert and oriented to self, but disoriented to time and place.”

How do you describe mood and affect?

Affect and Mood Affect is the patient's immediate expression of emotion; mood refers to the more sustained emotional makeup of the patient's personality. Patients display a range of affect that may be described as broad, restricted, labile, or flat.

How would you describe a client's affect?

AFFECT AND MOOD Mood is the underlying feeling state. Affect is described by such terms as constricted, normal range, appropriate to context, flat, and shallow. Mood refers to the feeling tone and is described by such terms as anxious, depressed, dysphoric, euphoric, angry, and irritable.

How do you document patient behavior?

In the patient's medical record, document exactly what you saw and heard. Start with the date and time the incident occurred, the location, and who was present. Describe the patient's violent behavior and record exactly what you and the patient said in quotes.

How do you describe mental status?

Examination of Mental Status. The mental status examination is an assessment of current mental capacity through evaluation of general appearance, behavior, any unusual or bizarre beliefs and perceptions (eg, delusions, hallucinations), mood, and all aspects of cognition (eg, attention, orientation, memory).

What are examples of affect?

Affect is the outward expression of feelings and emotion. Affect can be a tone of voice, a smile, a frown, a laugh, a smirk, a tear, pressed lips, a crinkled forehead, a scrunched nose, furrowed eyebrows, or an eye gaze.

How do you describe patient behavior?

Statements about the patient's mood should include depth, intensity, duration, and fluctuations. Common adjectives used to describe mood include depressed, despairing, irritable, anxious, angry, expansive, euphoric, empty, guilty, hopeless, futile, self-contemptuous, frightened, and perplexed.

What are types of affect?

Types of affect include:euthymic,irritable,constricted,blunted,flat,inappropriate,labile.

What are the 4 main components of a mental status exam?

What are The four main components of the mental status assessment? And the Acronym to help remember? are appearance, behavior, cognition, and thought processes.

When assessing a patient's mental status it is most important to consider?

The mental status exam should include the general awareness and responsiveness of the patient. Additionally, one may also include the orientation, intelligence, memory, judgment, and thought process of the patient. At the same time, the patient's behavior and mood should undergo assessment.

What are the 5 categories of the mental status exam?

The MSE can be divided into the following major categories: (1) General Appearance, (2) Emotions, (3) Thoughts, (4) Cognition, (5) Judgment and Insight.

What is included in a mental health assessment?

During the assessment, your doctor will gauge your ability to think clearly, recall information, and use mental reasoning. You may take tests of basic tasks, like focusing your attention, remembering short lists, recognizing common shapes or objects, or solving simple math problems.

What is mental status exam?

The mental status exam is a critical component of evaluations, across the helping professions.

Why does Affect feel down?

She described her mood as “down” most days. She said when she felt down, it was usually because “I’m always alone now, since my husband died three years ago.”

Do examiners use checklists?

Some examiners prefer the convenience of a checklist when conducting an MSE, which they can later expand upon in drafting a formal report.

Can MSE questions be modified?

The MSE questions below can be modified to fit the types of clients with whom you typically work.

What is mental status?

Definition. The mental status examination is a structured assessment of the patient's behavioral and cognitive functioning. It includes descriptions of the patient's appearance and general behavior, level of consciousness and attentiveness, motor and speech activity, mood and affect, thought and perception, attitude and insight, ...

When should a structured mental status examination be performed?

When there is history or evidence of clinically significant psychiatric illness, such as aberrant behavior or thinking, abnormalities on neurologic examination, or difficulties in day-to-day performance on the job or in social situations, then a formal dissecting of specific cognitive abilities should be performed near the close of the physician–patient encounter. When this is done, the examination needs to be introduced carefully to the patient, with some explanation as to why it is being done, in order to enlist patient cooperation rather than resistance. The structured mental status examination should focus on the observations listed in Table 207.1.

What is the most clinically relevant mental exam?

The specific cognitive functions of alertness, language, memory, constructional ability, and abstract reasoning are the most clinically relevant. The mental status examination is a structured assessment of the patient's behavioral and cognitive functioning. It includes descriptions of the patient's appearance and general behavior, ...

How to test for attentiveness?

An ideal test of attentiveness should assay concentration on a simple task, placing minimal demand on language function, motor response, or spatial conception. Reaction times are frequently slowed in patients who have diminished attentiveness. This may become evident early in the course of examination and provide an important clue that the examiner is dealing with decreased attentiveness. One test often recommended is the ability to listen to digit spans of increasing length and repeal them back to the examiner. Another is to have the patient listen to a digit span and then repeat it backward. Perhaps a better test is to have the patient listen to a string of letters in which one letter is repeated frequently but randomly and to tap each time that letter is heard, for example, "Please tap each time you hear the letter K."

How is repetition tested?

Repetition is tested by having the patient repeat sentences with several nouns and pronouns, for example, "That's what she said to them yesterday," and "No ifs, ands, or buts."

What is the purpose of feelings aroused by the examiner?

These data are sometimes subtle and easily overlooked as the examiner, in an attempt to remain objective, fails to note how he or she is responding to the patient.

How to test for immediate recall?

Immediate recall can be tested once again by having the patient repeal digit spans, both forward and backward. Long-term memory can be tested by the patient's ability to recall remote personal or historic events (e.g., the naming of previous presidents, major wars, date of the bombing of Pearl Harbor) or answer select questions from the WAIS information subtest. Obviously, in asking remote personal events, the physician must be privy to accurate information to judge the accuracy of the patient's response.

What is mental status?

The mental status examination is the psychiatrist’s version of the physical examination. In 1918, Adolf Meyer developed an outline for a standardized method to evaluate a patient’s “mental status” for psychiatric practice.[1] It combines information gathered from passive observation during the interview with data acquired through direct questioning ...

Why is it important to compare mental status to previous ones?

In subsequent encounters, comparing the mental status examination to previous ones will help the clinician to determine if a patient’s symptoms are improving or worsening .[1] Additionally, aspects such as observation of motility may indicate whether a patient is experiencing side effects from medications.

How to describe a patient in distress?

If a patient is in distress it may be due to underlying medical problems causing discomfort, a patient having been brought against their will to the hospital for psychiatric evaluation, or due to the severity of their hallucinations or paranoia terrifying the patient. Next, a description of their interaction with the interviewer should be noted.[2] For example, is the patient cooperative, or are they agitated, avoidant, refusing to talk, or unable to be redirected? A patient that is not cooperative with the interview may be reluctant if the psychiatric evaluation was involuntary or are actively experiencing symptoms of mental illness. Patients that are unable to be redirected often are acutely responding to internal stimuli or exhibit manic behavior. Lastly, it is important to note if the behavior the patient is displaying is appropriate for the situation. For example, it can be considered appropriate for a patient who was brought in via police for involuntary evaluation to be irritable and not cooperative. However, if in that same scenario, the patient was laughing and smiling throughout the interview, it would be considered inappropriate.

How to assess attention/concentration?

Attention/concentration is assessable throughout the interview by observing how well a patient stays focused on the questions asked .[3] Alternatively, this can be directly tested in a multitude of ways. One way is to ask a patient to tap their hand every time they hear a certain letter in a string of random letters. If they have good math skills, then another method is to ask the patient to count back from 100 by 7. Additionally, a practitioner may ask a patient to spell a word forwards and backward or ask them to repeat a random string of numbers forward and backward. [2][6]Impairment in attention/concentration may be a symptom of anxiety, depression, poor sleep, or a neurocognitive disorder.[3] When describing the patient’s performance, a practitioner may document the performance as poor, limited, fair, or in the case of a previous comparison worsening versus improving. Additionally, a practitioner can specifically describe the task and the patient’s performance.

What does it mean to look older in a clinical interview?

Details to be included are if they look older or younger than their stated age, what they are wearing, their grooming and hygiene, and if they have any tattoos or scars. If a patient looks more youthful than their stated age, they may have a developmental delay or dress in an age-inappropriate manner. Patients that look older than their stated age may have underlying severe medical conditions, years of substance abuse, or often years of poor ly controlled mental illness. Grooming and hygiene can give an idea of a patient’s level of functioning. Those with poor hygiene and grooming generally denote that in the context of their mental illness that they currently have poor functioning. Those with poor grooming or hygiene may be severely depressed, have a neurocognitive disorder, or be experiencing a negative symptom of a psychotic disorder such as schizophrenia. [2][4]Tattoos and scars can paint a picture of a patient’s history, personality, and behaviors. Scars tell stories about old, significant injuries from accidental trauma, harm caused by another individual, or self-inflicted harm. Self-inflicted injuries frequently include superficial cutting, needle tracks from IV drug use, or past suicide attempts.[2] Tattoos often are the name of a family member, significant other, or lost loved one. They can also depict gang marks, vulgar imagery, or extravagant artwork. If a certain level of trust has been established through the interview, the interviewer can ask about the significance of the tattoos or scars and what story they tell about the patient.

Why do patients deny hallucinations?

This may either be due to paranoia or fear generated by what they are experiencing. Even if a patient denies experiencing hallucinations, it is important to note whether the patient appears to actively respond to internal stimuli by talking to someone not present or looking at something not present.

What are the qualities of speech in psychiatric interview?

The qualities to be noted are the amount of verbalization, fluency, rate, rhythm, volume, and tone. It is of key importance to note the amount a patient speaks. If the patient speaks less than normal, they may be experiencing depression or anxiety.

What is mental status evaluation?

A mental status evaluation is a necessary part of any client assessment no matter what the presenting problem. It should be documented in the record either in list form or in narrative form. This article illustrates both the list and the narrative. The following client functions should be included. 1.

What is thought process testing?

Thought Processes/Reality Testing - describes client’s thinking style and ability to know reality, including the difference between stimuli which are coming from inside herself/himself and those which are coming from outside herself/himself. Statements about delusions, hallucinations, and conclusions about whether or not the client is psychotic would appear here.

What is the meaning of "impulsive potential for harm"?

5. Impulsive/Potential For Harm - assesses impulse control with special attention to potential suicidality and/or harm to others.

Do managed care companies have expectations?

Managed care companies often have expectations about how the mental status should be documented in the record. These should, of course, be followed.

When assessing moods, psychologists consider whether the respondent is reporting honestly or is faking a?

When assessing moods, psychologists consider whether the respondent is reporting honestly or is faking a response (i.e., exaggerating or underreporting his or her problems and emotional state). Inaccurate or “faked” responses are more likely when an evaluation is conducted to decide about employment, child custody, or prison release, or to obviate or attenuate a court verdict.

How to assess mood?

Methods of Assessing Mood. The most common way to assess mood is the clinical or assessment interview. Mood is an element in the overall assessment process in almost every published recommendation on interviewing and is a routine part of both a psychiatric and a mental status examination.

How long does it take to complete the Guilford Zimmerman Temperament Survey?

It takes from 30 to 60 minutes to complete and can be scored via local software, mail-in scoring, or optical scan scoring. It provides scores on 10 aspects of personality and temperament (e.g., energy versus inactivity, impulsivity versus restraint, friendliness versus hostility, and stability versus irritability). A computer-derived interpretive report is available from the publisher. The GZTS was designed for use in counseling, career planning, personnel selection, and placement with nonclinical populations.

How many scales are there in MMPI 2?

Four scales of the MMPI-2 assess the respondent’s anxiety level—one clinical scale (Psychasthenia, or Pt), two content scales (Anxiety and Fears), and one supplemental scale (Welsh’s Factor A).

What is the Fears content scale?

The 23-item Fears content scale assesses apprehension about a particular object or circumstance and a fear of harm or injury. It has two components. The Generalized Fears component measures respondents’ feelings of persistent danger, and the potential harmfulness of objects or environmental circumstances. The Multiple Fears component assesses more specific fears such as fears of common objects or circumstances.

What are the three scales of mood?

The MCMI-III contains three scales that assess for problematic mood. The 14-item Dysthymia scale asks about the absence of pleasure, loss of energy, guilt feelings, sadness, changeable moods, and general disparagement . The 17-item Major Depression scale assesses loss of energy and appetite, problems sleeping, general fatigue, absence of pleasure, feelings of emptiness, intrusive memories, suicidal thoughts, admission of past suicide attempt (s), and reports of repression. Finally, the Bipolar: Manic scale contains 13 items dealing with overactivity, elation and inflatedness, flight of ideas, variable moods, overtalkativeness, and impulsivity. The Depressive Personality Disorder scale assesses a clinical personality pattern rather than mood, but there is much redundancy between the personality disorder and mood scales.

Why is a clinical interview unstructured?

A clinical interview may appear to be unstructured because the psychologist does not appear to ask a set of predetermined questions. Nevertheless, the skilled interviewer will make sure to ask questions about each of the areas regarded as relevant to the question, problem, or disorder at hand.

What is a mental status assessment?

A mental status examination can be an abbreviated assessment done because someone appears to be in obvious need of hospitalization, or it can be an elongated process that takes place over several interviews. The MSE always has the same content, and you write your observations in roughly the same order each time.

What is affect in psychology?

Affect refers to the underlying flow of moods. This would be the outward expression of the emotional state. You can see it in the way patients use and position their bodies and in their tone and manner of speaking. You may find it broad, appropriate, constricted, blunted, flat, labile, or anhedonic.

What is the outline of the DSM IV?

Anthony LaBruzza (1994), in his book Using DSM-IV, provides a good outline for the mental status report that you will complete after the interview. He stated that his outline is not meant to be followed precisely, but it does give the major points and a framework to determine what is important. The outline in Figure 18.2 [not shown here] provides the major categories you must cover in a mental status report.

How to back up observations?

To back up your observations, use both descriptions of the individual's behavior during the interview and direct quotes made by the person in the interview. In this way, you carefully document your observations and your resulting conclusions.

What is the form of a person's thoughts?

You may find the form of the person's thoughts to be spontaneous, logical, goal directed, coherent, impoverished, blocking, nonspontaneous, incoherent, perseverative, circumstantial, tangential, or illogical. You may find it to have loose associations or flight of ideas. You may find that it contains neologisms or is distractible.