22 hours ago · Mental Status Report 1. Gary Sparrow, a 48-year-old white male, was disheveled and unkempt on presentation to the hospital emergency room. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was agitated and restless, frequently changing seats. >> Go To The Portal
Certain tests, including the Mini Mental Status Exam, seek to eliminate ambiguity and concretely define a patient's overall cognitive ability. When The Test Is Used There are several different mental status teststhat can be implemented to gather information to diagnose a patient with dementia, or monitor the progressionof the condition.
•Observe for noticeable evidence of weight loss or gain if seeing the patient serially. •Generalized "psychomotor retardation" is often the most common symptom of depression seen in a mental status exam. What this means is you will see visible generalized slowing of movements and speech.
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).
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. The patient care plans often have to be altered when there are observable abnormalities on the mental status exam.
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...•
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.
The following is a brief example of a mental status exam: Appearance: The client is slouched and disheveled. General behavior:The client is uncooperative and has poor eye contact. Speech:The client speaks fast and soft.
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?
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.
Common words used to describe a mood include the following: Anxious, panicky, terrified, sad, depressed, angry, enraged, euphoric, and guilty. Once should be as specific as possible in describing a mood, and vague terms such as “upset” or “agitated” should be avoided.
Common adjectives used to describe mood include depressed, despairing, irritable, anxious, angry, expansive, euphoric, empty, guilty, hopeless, futile, self-contemptuous, frightened, and perplexed.
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.
To write a mental health assessment, start by writing a detailed explanation of everything that is affecting the patient and how it is affecting them. Include a detailed description of the patient's mental health problem, as well as any social or medical history that may have caused the problem.
Overview. Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. Also called major depressive disorder or clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems.
Affect is the outward display of one's emotional state. One can express feelings verbally, by talking about events with emotional word choices and tone. A person's affect also includes nonverbal communication, such as body language and gestures. Blunted affect is a markedly diminished emotional expression.
MENTAL STATUS EXAMINATION: This is a patient who appears to be of stated age, casually and neatly dressed and in no acute distress. The patient engaged the examiner in a cooperative, friendly and polite manner. The patient demonstrated good eye contact. His speech was spontaneous with normal rate, rhythm and tone. His reaction time to questions was normal. While his affect was appropriate to the situation, his mood was euthymic with no evidence of depression, guilt feelings and suicidal or homicidal ideation at this time. His stream of mental activity was logical, relevant, coherent and goal directed with no evidence of flight of ideas, looseness of associations, thought blocking, psychomotor retardation, pressured speech, racing thoughts, circumstantiality or tangentiality. His thought content revealed no evidence of delusional ideation, interference or responses to internal stimuli, hallucinations, ideas of reference, mood swings, compulsions, obsessions, or any specific preoccupations. The patient was alert and oriented in all three spheres. His memory was intact including his immediate, recent past and remote memory. His attention and concentration were intact. His fund of general information was good. The patient was able to perform simple arithmetic calculations and serial subtraction by 7s. His comprehension and understanding were good. Therefore, his intelligence was estimated to be above average; consistent with his level of formal education. His abstraction of proverbs and symbolization were good. His judgment, insight and reliability appeared to be good.
MENTAL STATUS EXAMINATION: Showed a medium-built male with labile affect. Oriented x3. Insight was poor. Judgment was very poor. Behavior was hyperactive. Denies any suicidal or homicidal ideations. Denies hallucinations. Memory appeared to be grossly intact. Cognitive functioning appeared to be impaired. Speech was pressured and rambling. Trend of thought showed ideas of grandeur and omnipotence. Mood was expansive but also was quick to change to anger. Intelligence was average. Reality testing appeared to be impaired.
The Mini Mental Status Exam (MMSE) is one of these tests, and is administered to patients at risk for or suspected of developing dementia. The test was developed around 1975, and has been used to track an individual's mental deterioration over time.
The Mini Mental Status Exam is a brief test given to patients at risk or suspected of developing dementia; it measures memory, orientation and math skills.
Diagnosing dementia can be difficult because symptoms typically occur graduallyand are often associated with many different disorders. Certain tests, including the Mini Mental Status Exam, seek to eliminate ambiguity and concretely define a patient's overall cognitive ability.
Scores in the bottom two categoriesstrongly indicate the presence of dementia.
Low scores are highly correlated with instances of dementia, but several other factorscan complicate the assessment—including physical injuries, other existing mental conditions and previous difficulty with math and/or language. The test cannot serve as an exclusive diagnosisof dementia, but it can be very useful as a complementary tool and a method to track a patient's progression as the disease develops.
Healthcare Brands does not endorse or provide any medical advice, diagnosis, or treatment. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition and cannot be substituted for the advice of physicians, licensed professionals, or therapists who are familiar with your specific situation. Consult a licensed medical professional or call 911, if you are in need of immediate assistance. Furthermore, the information reflects the opinions of the author alone and not those of the author’s employer or Healthcare Brands. For more information, please carefully read our Privacy Policythe Terms and Conditions of Use.
A mental status exam template is a document where you record your evaluation of a patient’s current mental capacity by observing his behavior, general appearance, any bizarre or unusual perceptions and beliefs, mood, and all other aspects of cognition.
The main objective of a mental status exam template is to gather evidence of any signs or symptoms of a mental disorder that includes posing a danger to the self and other people present during the interview.
Naming Objects. Present an object to the patient then ask him to name the object and its different parts. Following Instructions. Start with 1-step instructions. If the patient can follow, increase to 2-step instructions. Then move on to 3-step instructions to see if the patient can really follow. Writing.
A mental status exam is similar to a physical exam, although here, the examination assesses a person’s mental status. It involves a series of examinations and observations designed to reveal either pathological or normal findings. Then you would record all of your observations and results in a mental status exam template.
The information gathered during the interview is usually recorded as free-form text with standard headings but there are shorter mental status exam templates available that you can use in case of emergency. Together with the social and biographical data of the patient’s psychiatric history, you can use the information gathered in the mental status exam form to generate a psychiatric formulation, a diagnosis, and a plan for the patient’s treatment.
The results recorded in the mental status exam form can only produce a “snapshot” of your patient.
You must inform patients that recording of mental status is a routine procedure and that they don’t have to feel embarrassed by it . The setting of the examination is usually a quiet room. As an examiner, you should make sure the patient can hear the questions clearly.
Lucia Rodriguez, a 24-year-old Latino female, was open, pleasant, and cooperative during our meeting. She was well-groomed and looked somewhat younger than her stated age. She was fully oriented and alert. Her speech was clear, coherent, and of normal rate and volume. Her affect was euthymic and stable. She rated her mood as an “8” on a 0-10 scale, with 0 being completely down and depressed and 10 being as happy as possible. She further indicated that she is typically in a “positive mood.” Lucia has no current obsessional thoughts or psychotic symptoms. She has no significant mental health history. Her intellectual ability is probably at least in the above average range. She completed serial sevens and other concentration tasks without difficulty. Her cognitive skills, including memory and abstract thinking were intact. Her responses to questions pertaining to social judgment were positive and well-developed. Overall she appeared forthright and reliable. Her insight and judgment were good.
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.
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.
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.
Nevertheless, subjective judgment and inference is always a part of MSEs and MSE reports.
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.
A delayed speech response time may also indicate a neurocognitive disorder or that the patient is experiencing a thought process disorder such as thought blocking seen in psychosis. The rhythm of speech can provide clues to a number of diagnoses. Slurred speech may indicate intoxication.
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.
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.
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.
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.
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.