how to report patient 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?

Common screening tools used frequently by registered nurses to assess mental status include the Glasgow Coma Scale, the National Institutes of Health Stroke Scale (NIHSS), and the Mini-Mental State Exam (MMSE).

How do nurses assess 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 would you describe a patient's mental status?

Descriptors of a patient's level of consciousness include alert, clouded, somnolent, lethargic, and comatose. Elements of a patient's cognitive status include attention, concentration, and memory.

How do you do a mental status assessment?

Mental Status ExaminationAppearance. Record the patient's sex, age (apparent or stated), race, and ethnic background. ... Attitude toward the examiner. Next, record the patient's facial expressions and attitude toward the examiner. ... Mood. ... Affect. ... Speech. ... Thought process. ... Thought content. ... Insight.More items...•

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 a patient's affect?

Examples of descriptors for affect include sad, depressed, anxious, agitated, irritable, angry, elated, expansive, labile, inappropriate, incongruent with content of speech.

How would you describe a patient mood and 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.

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.

How do you document patient orientation?

In certain health assessments, orientation is sometimes referred to as "alert and oriented" (AO or A&O) or "awake, alert, and oriented" (AAO). It is usually followed by the multiplication symbol (x) and a number. For example, it may be written like "AOx3" or "AAOx4."

What should I write in MSE?

The Domains Included in the MSE: 14 Examples Awareness of date/time, current location, and current situation (e.g., reason for appointment). The client's gait, posture, manual dexterity, etc. Is the client neatly dressed or more disheveled?

How do you write a mental health nursing note?

Tips for Writing Mental Health Nursing NotesEnsure your notes begin with identifying information, such as the patient's name, age and birthdate.Avoid jargon and abbreviations.Write in short, clear and complete sentences.Do not copy and paste information from other documents into your notes.More items...•

What is a mental status assessment nursing?

The Mental Status Examination (MSE)—a structured assessment of client's behavioural and cognitive functioning—is a vital component of nursing care that assists with evaluation of mental health conditions.

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 ...

What are the categories of mental status examination?

For the purposes of this activity, the mental status examination can divide into the broad categories of appearance, behavior, motor activity, speech, mood, affect, thought process, thought content, perceptual disturbances, cognition, insight, and judgment.

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.

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.

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.

What is a less detailed report?

Less detailed reports are more common when the situation is less complex and the patient or client displays affect and behaviors that are generally within what might be considered a broad range of normal. In most cases MSEs are imbedded within a clinical or psychiatric interview.

What is MSE report?

Mental Status Examination (MSE) reports can be more or less detailed. More detailed reports are necessary when patients or clients exhibit a complex array of psychiatric symptoms, affect, and behavior. Less detailed reports are more common when the situation is less complex and the patient or client displays affect and behaviors that are generally within what might be considered a broad range of normal.

Is subjective judgment a part of MSE?

Nevertheless, subjective judgment and inference is always a part of MSEs and MSE reports.

Can MSEs be reflected in a clinical interview?

In most cases MSEs are imbedded within a clinical or psychiatric interview. As a consequence, as an evaluator, sometimes you may obtain more information about certain areas of functioning than others. This may or may not be intentional and it may or may not be reflected in your report.

What are the tools used to assess mental health?

There are many screening tools that can be used to further objectively assess a patient’s mental status and cognitive impairment. Common screening tools used frequently by registered nurses to assess mental status include the Glasgow Coma Scale, the National Institutes of Health Stroke Scale (NIHSS), and the Mini-Mental State Exam (MMSE).

How many points can a patient score on the MMSE?

Prior to administering the MMSE, ensure the patient is wearing their glasses and/or hearing aids, if needed. [9] A patient can score up to 30 points by accurately responding and following directions given by the examiner. A score of 24-30 indicates no cognitive impairment, 18-23 indicates mild cognitive impairment, and a score less than 18 indicates severe cognitive impairment. See Figure 6.10 [10] for an image of one of the questions on the MMSE regarding interlocking pentagons.

What is the Glasgow Coma Scale?

The Glasgow Coma Scale (GCS) is a standardized tool used to objectively assess and continually monitor a patient’s level of consciousness when damage has occurred, such as after a head injury or a cerebrovascular accident (stroke). See Figure 6.9 [6] for an image of the Glasgow Coma Scale. Three primary areas assessed in the GCS include eye opening, verbal response, and motor response. Scores are added from these three categories to assign a patient’s level of responsiveness. Scores ranging from 15 or higher are classified as the best response, less than 8 is classified as , and 3 or less is classified as unresponsive.

What is the stroke scale?

The National Institutes of Health Stroke Scale (NIHSS) is a standardized tool that is commonly used to assess patients suspected of experiencing an acute cerebrovascular accident (i.e., stroke). [7] The three most predictive findings that occur during an acute stroke are facial drooping, arm drift/weakness, and abnormal speech. Use the following hyperlink to view the stroke scale.

What is a normal level of orientation?

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.”. [5] If a patient is confused, an example of documentation is, “Patient is alert and oriented to self, but disoriented to time and place.”.

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 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.

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.

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 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.

Primer

The Mental Status Exam (MSE) is a systematic way of describing a patient's mental state at the time you were doing a psychiatric assessment.

Emotion

Affect is momentary (like the weather), while, mood is a prolonged emotion (like the climate). Hence, “mood is climate, and affect is the weather.” [2]

Thought Content

Delusions (erotomanic, grandiose, jealous, persecutory, and somatic themes?)

Insight

What is the patient's understanding of the world around them and their illness?

Judgment

What have the patient's actions been? Have they done anything to put themselves or other people at harm?