Mental Status Exam

Patient presents as [select value="alert and oriented to |disoriented to |"][select value="person, place, and time|"][textarea rows="1"].  [select value="Recent and remote memory are intact|Recent memory is intact, although issues with remote memory include |Remote memory is intact, although issues with recent memory include |Issues with recent and remote memory are noted to be |"][textarea memo="additional information about memory" rows="3"].  [select value="Attention span and concentration are adequate|Difficulty with attention span and concentration are evidenced as "][textarea rows="2"]. Their language skills are [select value="adequate, |limited, |difficult to assess due to the degree of symptomatic presentation|"][select value="and consistent with education|and inconsistent with education|"][textarea rows="1"]. Their fund of knowledge is [select value="appropriate for stated age and education level|inappropriate for stated age and education level|difficult to assess due to symptomatic presentation|"][textarea rows="2"].  [select value="They are capable of abstraction|They display difficulty with abstraction|Assessment of abstraction ability difficult due to symptomatic presentation"][textarea rows="1"]. They appear to be [select value="their stated age|younger than their stated age|older than their stated age|"][textarea rows="1"].  They are [select value="well groomed|unkempt|"], [select value="appropriately dressed|inappropriately dressed|"][textarea rows="1"], [select value="in their own clothes|in hospital clothes|"][textarea rows="1"], with [select value="normal posture|slumped posture|rigid posture|"][textarea rows="3"]. Their behavior presents as [select value="calm|restless|agitated|irritable|anxious|impulsive|"][textarea rows="1"], and [select value="interactive|inattentive|withdrawn|"][textarea rows="1"][select value=" with good eye-contact| with intermittent eye-contact| with avoidant eye-contact"][textarea rows="2"]. [select value="Their gait presents as |They are incapable of ambulating|"][select value="normal|abnormal|unsteady|shuffling|spastic|"][textarea rows="1"].  [select value="Muscle strength and tone are |"][select value="equal for all limbs with free range of motion|"][textarea rows="2"]. Speech is [select value="a regular rate and rhythm|rapid|slow|"][textarea rows="1"][select value=", spontaneous|, appears prepared|"][select value=", fluid, slurred|, monotone|, pressured|, laconic|"][select value=", normal volume|, quiet|, loud|"][textarea rows="2". Vocabulary is [select value="adequate|large|limited|difficult to assess due to symptomatic presentation|"][textarea rows="1"].  Thought processing and content present as [select value="adequate, |delayed, |"][select value="logical, |illogical, |"][select value="reality based|"][checkbox name="thoughts" memo="additional descriptors" value=""][conditional field="thoughts" condition="(thoughts).is('')"][checkbox value="disorganized|circumstantial|tangential|flight of ideas|loose association|perseveration|thought blocking|ideas of reference|grandiose|paranoid|persecutory|religious|somatic|self accusatory"][/conditional][textarea rows="2"].  [select value="No evidence of hallucinations or delusions|Hallucinations/delusions characterized as "][textarea rows="2"].  [select value="No evidence of preoccupation with violence|They have a reoccupation with violence as evidenced by |"][textarea rows="2"].  [select value="They deny suicidal ideation|They report positive for suicidal ideation without intent|They report positive for suicidal ideation with intent |"][textarea rows="2"].  [select value="They deny homicidal ideation|They affirm homicidal ideation toward |"][textarea rows="1"].   Their judgment concerning everyday activities is [select value="good|fair|poor|impaired|"][textarea rows="1"].  Their insight concerning their psychiatric condition is [select value="good|fair|poor|impaired|"][textarea rows="1"].
Patient presents as . additional information about memory. . Their language skills are . Their fund of knowledge is . . They appear to be . They are , , , with . Their behavior presents as , and . . . Speech is . Thought processing and content present as additional descriptors. . . . . Their judgment concerning everyday activities is . Their insight concerning their psychiatric condition is .

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.58, 61 form elements, 45 boilerplate words, 25 text areas, 2 checkboxes, 33 drop downs, 1 conditionals, 73 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

This site uses Akismet to reduce spam. Learn how your comment data is processed.

More SOAPnotes by this Author: