CMH – Case Note – Detailed

[textarea cols="40" rows="1" default="PATIENT"] was seen [textarea cols="40" rows="1" default="alone with the author"] in [textarea cols="40" rows="1" default="setting"].

MENTAL STATUS EXAMINATION 

-- Appearance and Self-Care --

Stature:  [select value="Average|Small|Tall"]
Weight: [select value="Average weight|Overweight|Obese|Underweight"] - Weight [text name="field_name" default="not assessed"]
Clothing: [select value="Neat/clean|Careless|Inappropriate|Meticulous|Disheveled Dirty|Bizarre"]
Grooming: [select value="Unremarkable|Meticulous|Neglected|Bizarre"]
Cosmetics: [select value="Unremarkable|Inappropriate for age|Excessive|None"]
Posture: [select value="Normal|Tense|Rigid|Stooped|Slumped|Bizarre"]
Motor activity:  [select value="Unremarkable|Slowed|Repetitive|Restless|Agitated|Tremor"]
Other noticeable aspects: [textarea name="field_name" default="Nil"]

-- Sensorium --

Attention: [select value="Normal|Unaware|Inattentive|Distractible|Vigilant"]
Concentration: [select value="Normal|Scattered|Variable|Preoccupied|Confused|Anxiety interferes|Focuses on irrelevancies"]
Orientation Impairment: [checkbox name="Orientation" value="Nil|Time|Person|Place|Situation|Object"]
Memory Impairment: [checkbox name="MemImp" value="Nil|Working memory|Short term|Recent|Remote|Particular events|Confabulates|Amnesiac"]

-- Relating --

Eye contact: [select value="Normal|Fleeting|Avoidant|None|Staring"]
Facial expression: [select value="Responsive|Constricted|Tense|Anxious|Sad|Depressed|Angry"]
Attitude toward author: [select value="Cooperative|Dependent|Dramatic|Passive|Uninterested|Silly|Resistant|Critical|Hostile|Sarcastic|Irritable|Threatening|Suspicious|Guarded|Defensive|Manipulative|Argumentative"]

-- Affect and Mood --

Affect: [select value="Appropriate|Labile|Restricted|Blunted|Flat"]
Mood: [select value="Euthymic|Anxious|Angry|Apathy|Ashamed|Prideful|Sad|Irritable|Hostile|Pessimistic|Depressed|Hypomanic|Euphoric"] -- [text name="field_name" default="other"]
Mood rated out of 10: [select value="Not rated|1|2|3|4|5|6|7|8|9|10"]

-- Thought and Language -- 

Speech flow: [select value="Normal|Mute|Loud|Blocked|Paucity|Pressured|Flight of ideas"]
Thought content: [select value="Congruent with mood and circumstances|Incongruent Congruent with mood and circumstances|Personalizations|Persecutions|Indecisions|Suspicions|Delusions|Ideas of reference|Ideas of influence|Illusions"]
Thought organisation: [select value="logical and goal directed|Circumstantial|Tangential|Loose associations|Flight of ideas|Neologisms|Blocking|Obsessive"]
Preoccupations: [select value="Nil|Phobias|Somatic|Suicide|Homicidal|Guilt|Religion"] - Other: [text name="field_name" default="Nil"]
Hallucinations: [select value="Nil|Auditory|Visual"] 
Hallucination content: [text name="HalCon" default="N/A"]

-- Executive Functions --

Fund of knowledge: [select value="Average|Above average|Impoverished"]
Intellectual functioning: [select value="Average|Below average|Above average|Needs Assessment"]
Abstraction: [select value="Normal|Concrete|Functional|Popular|Abstract|Overly abstract"]
Judgment: [select value="Sound|Fair|Poor|Dangerous"]
Reality testing: [select value="Realistic|Adequate|Distorted|Variable|Unaware"]
Insight: [select value="Makes connections|Gaps|Occasional|Unaware|Nil|In denial"]
Decision making: [select value="Normal|Simplstic|Impulsive|Vacillates|Confused|Paralyzed"]

-- Current Stressors -- 

Stressors: [checkbox name="Stressors" value="Money|Housing|Family conflict|Work|Grief and loss|Illness|Transitions|Legal difficulties|Peer group|Relationship"]
Coping ability: [select value="Normal|Resilient|Exhausted|Overwhelmed|Deficient supports"]
Skill deficits: [checkbox name="SkillDefs" value="None|Education|Communication|Interpersonal|Decision making|Self control|Responsibility|Self care|Activities of daily living"]
Supports: [checkbox name="Supports" value="Self|Family|Friends|Parole officer|Church|NGO|GP"] Other: [text name="field_name" default="Other supports"] 
Supports needed: [textarea name="field_name" default="No other supports needs at this time"]

-- Social Functioning -- 

Social maturity: [select value="Responsible|Irresponsible|Self-centered|Impulsive|Isolates"]
Social judgment: [select value="Normal|Street smart|Naive|Heedless|Victimized|Improper"]

-- Risk -- 

Suicide: [select value="no active suicidal ideation|Vague suicidal ideation|intense suicidal ideation|Has a suicide plan without intent|Has strong intent to suicide without plan|Has strong intent and a plan to suicide"]

-- Other Aspects of Mental Status --

[textarea name="field_name" default="Nothing to report"]

PRESENTING CONCERNS

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Next appointment: [textarea cols=50 rows=1 default="has not been arranged"]