MSE 6/4/22 1323

Psychiatry & Psychology
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Mental Status Exam
Appearance: [select name="race" value="White|Black|Hispanic|"][conditional field="race" condition="(race).is('')"] [text ][/conditional] [select name="sex" value="male|female|transgender female|transgender male"], appearing [select name="appearance" value="approximately same as|younger than|older than"] chronological age, [checkbox name="build" value="normal build, wearing hospital gown|normal build|overweight|obese|underweight|emaciated|thin|muscular build|wearing hospital gown|wearing paper scrubs|casually dressed|oddly dressed|partially undressed"][select name="grooming" value=", adequate hygiene and grooming|, disheveled appearing|, well-groomed|, grooming notable for"] [text]
Attitude/Behavior: [checkbox name="attitude" value="lying down in bed|sitting up in bed|sitting on side of bed|sitting in bedside chair|pacing, walking around room|calm and cooperative, engages easily, socially appropriate|calm|irritable|restless|agitated|impatient|guarded|defensive|argumentative|resistant to psychiatry|poor effort and cooperation|cooperative|uncooperative|eventually cooperates|reluctantly cooperates|intermittently cooperative|easily engages|difficult to engage|socially appropriate|socially inappropriate at times|disinhibited behavior|notable grimacing with positional changes|lying in urine|lying feces|poor social awareness"]
[text name="Behx" default=";"][select name="eyecontact" value="fair|good| poor|intermittent|intense|refuses|no"] eye contact
Motor Activity: [checkbox name="motor" value="normal level of activity, no abnormal movements|increased level of activity|decreased level of activity|psychomotor agitation|psychomotor retardation|no abnormal movements|tremulousness|+tremor|+tic|+dystonia"][text size=65]
Intellectual Functioning: [checkbox name="IntFxn1" value="estimated to be average|estimated to be below average|estimated to be above average|"] [select name="IntFxn2" value="|based on "][checkbox name="IntFxn3" value="interview responses|educational attainment|occupational functioning|fund of general knowledge|ability to engage in abstract thinking|"]




Memory Functioning
Rate as Intact or Impaired

Supporting Evidence: Responses to the following questions:

Recent Memory:

What is my name?
What medications did you take today?
What time was your appointment with me today?
Remote Memory:

What is your Social Security number?
What was the date of your graduation from high school?
When and where did you get married?
Where were you when President Kennedy was shot? (for patients over 40)
Immediate Memory:

Recall of three words (color, object, animal – e.g., blue, table, horse) after 5 minutes

Instructions: I’m going to ask you to remember three words and I will ask you to repeat them to me in 5 minutes. Please repeat them now after me: blue, table, horse. (5 minutes elapses.) What were those 3 words I asked you to remember?

Orientation
Person, place, date, situation

Supporting Evidence: Responses to the following questions:

What is your full name?
Where are we right now? (city, state, building)
What is the full date today? (date, month, year) and season of the year?
How would you describe the situation we are in?
Insight
Rate as Full, Partial, or Limited understanding of illness

Supporting Evidence: Responses to the following questions:

What has brought you here today?
What do you think is the problem?
What do you think is causing your problems?
How would you describe your role in this situation?
Do you think there is anything that will help you feel better?
Judgement
Rate as Good (able to anticipate outcomes); Adequate (able to use feedback to learn from mistakes); Fair (able to learn from some experiences); Poor (difficulty predicting results of choices)

Supporting Evidence: Responses to the following questions:

If you found a stamped, addressed envelope on the street, what would you do with it?
If you were in a movie theatre and smelled smoke, what would you do?
What would you do if you saw a train coming toward you on the track?
Mental Status Exam
Appearance: , appearing chronological age,
Attitude/Behavior:
eye contact
Motor Activity:
Intellectual Functioning:




Memory Functioning
Rate as Intact or Impaired

Supporting Evidence: Responses to the following questions:

Recent Memory:

What is my name?
What medications did you take today?
What time was your appointment with me today?
Remote Memory:

What is your Social Security number?
What was the date of your graduation from high school?
When and where did you get married?
Where were you when President Kennedy was shot? (for patients over 40)
Immediate Memory:

Recall of three words (color, object, animal – e.g., blue, table, horse) after 5 minutes

Instructions: I’m going to ask you to remember three words and I will ask you to repeat them to me in 5 minutes. Please repeat them now after me: blue, table, horse. (5 minutes elapses.) What were those 3 words I asked you to remember?

Orientation
Person, place, date, situation

Supporting Evidence: Responses to the following questions:

What is your full name?
Where are we right now? (city, state, building)
What is the full date today? (date, month, year) and season of the year?
How would you describe the situation we are in?
Insight
Rate as Full, Partial, or Limited understanding of illness

Supporting Evidence: Responses to the following questions:

What has brought you here today?
What do you think is the problem?
What do you think is causing your problems?
How would you describe your role in this situation?
Do you think there is anything that will help you feel better?
Judgement
Rate as Good (able to anticipate outcomes); Adequate (able to use feedback to learn from mistakes); Fair (able to learn from some experiences); Poor (difficulty predicting results of choices)

Supporting Evidence: Responses to the following questions:

If you found a stamped, addressed envelope on the street, what would you do with it?
If you were in a movie theatre and smelled smoke, what would you do?
What would you do if you saw a train coming toward you on the track?

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