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Patient presents as[checkbox value=" alert and oriented to "][checkbox value="person|place|time"][checkbox value=", disoriented to "][checkbox value="person|place|time"]. [checkbox value="Recent and remote memory are intact. "][textarea memo="additional information about memory" rows="3"] [checkbox value="Attention span and concentration are adequate. "][textarea memo="additional information about attention span/concentration" rows="3"] Their language skills are [checkbox value="adequate|limited|consistent with education|inconsistent with education"]. [textarea memo="additional information about language" rows="3"] Their fund of knowledge appears [checkbox value="appropriate for stated age and education level|inappropriate for stated age and education level"]. [textarea memo="additional information about fund of knowledge" rows="3"] [checkbox value="They are capable of abstraction. |They display difficulty with abstraction. "][textarea memo="additional information about abstraction" rows="3"] They appear to be [checkbox value="their stated age|younger than their stated age|older than their stated age|well groomed|unkempt|appropriately dressed|inappropriately dressed|in their own clothes|in hospital clothes|normal posture. |slumped posture.|rigid posture."][textarea memo="additional information about appearance" rows="3"] Their behavior presents as [checkbox value="calm|restless|agitated|irritable|impulsive|inattentive|interactive|withdrawn"] with [checkbox value="good eye-contact. |avoidant eye-contact. "][textarea memo="additional information about behavior" rows="3"] [checkbox value="They are incapable of ambulating|Their gait presents as "][checkbox value="normal|abnormal|unsteady|shuffling|spastic"]. [checkbox value="Muscle strength and tone are "][checkbox value="equal for all limbs with free range of motion"][textarea memo="additional information about muscle strength" rows="3"]. Speech is [checkbox value="a regular rate and rhythm|spontaneous|appears prepared|hyperverbal|rapid|slow|rambling|slurred|monotone|pressured|laconic|normal volume|quiet|loud"]. Vocabulary is [checkbox value="adequate|large|limited"]. [textarea memo="additional information about speech" rows="3"] Thought processing and content present as [checkbox value="adequate|delayed|logical|illogical|reality based|disorganized|circumstantial|tangential|flight of ideas|loose association|perseveration|thought blocking|ideas of reference|grandiose|paranoid|persecutory|religious|somatic|self accusatory"]. [textarea memo="additional information about thought process" rows="3"] [checkbox value="No evidence of hallucinations or delusions. "][checkbox value="No evidence of preoccupation with violence. "][checkbox value="They deny suicidal and homicidal ideation. "][textarea memo="additional information about thought content" rows="3"] Their judgment concerning everyday activities is [checkbox value="good. |fair. |poor. |impaired. "][textarea memo="additional information about judgment" rows="3"] Their insight concerning their psychiatric condition is [checkbox value="good. |fair. |poor. |impaired. "][textarea memo="additional information about insight" rows="3"]
Patient presents as . additional information about memory additional information about attention span/concentration Their language skills are . additional information about language Their fund of knowledge appears . additional information about fund of knowledge additional information about abstraction They appear to be additional information about appearance Their behavior presents as with additional information about behavior . additional information about muscle strength. Speech is . Vocabulary is . additional information about speech Thought processing and content present as . additional information about thought process additional information about thought content Their judgment concerning everyday activities is additional information about judgment Their insight concerning their psychiatric condition is additional information about insight
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