Psychiatry
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[remark]content[/remark]
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|wearing street clothes|oddly dressed|partially undressed|malodorous"][select name="grooming" value=", adequate hygiene and grooming|, disheveled appearing|, well-groomed|, grooming notable for"] [text].
Attitude/Behavior: [checkbox name="attitude" value="calm and cooperative, engages easily, socially appropriate|calm|difficult to redirect for interviewing|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|poor social awareness"] [text size=65 value=''][select name="eyecontact" value="; fair|; good|; poor|; intermittent|;intense|;refuses|;no"] eye contact.
Motor activity: [checkbox name="motor" value="lying down in bed|sitting up in bed|sitting on side of bed|sitting in bedside chair|pacing|walking around room|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|+catatonia"] [text size=65].
Gait/Station: [checkbox value="normal erect posture|not quite erect, slightly stooped posture|moderately stooped posture|severely stooped posture with kyphosis|slightly leaning to one side|moderately leaning to one side|marked flexion with extreme abnormality of posture||stable station|unstable when standing|unable to stand without assistance||normal gait|walks slowly|walks with difficulty but requires little/no assistance|severe disturbance of gait requiring assistance|cannot walk at all, even with assistance|unable to assess due to altered mental status|unable to assess due to current medical issues|unable to assess due to current symptomatic presentation"].
Speech: [select value="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"].
Language: [checkbox name="skills" value=" naming and repetition intact|naming skills intact,deficits in repetition|repetition skills intact, deficits in naming"]; vocabulary [select value="adequate|large|limited|difficult to assess due to symptomatic presentation|"]
[select value="|,expressions are often vague|and consistent with education|and inconsistent with education|"][textarea rows="1"][comment memo="Stilted speech- Sentences may be stilted or vague. Speech characterized by the use of words or phrases that are flowery, excessive, and pompous,e.g.The attorney comported himself indecorously."]
Thought process:[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"][/conditional][textarea rows="2"]. [select value="Capable of abstraction|Displays difficulty with abstraction|Assessment of abstraction ability difficult due to symptomatic presentation"][textarea rows="1"].
Thought content: [select value="Appropriate|Depressive themes|Over-valued ideas about "][textarea rows="2"].[select value="No evidence of delusions|Delusions characterized as "][textarea rows="2"]. [select value="No evidence of preoccupations|Preoccupation with |"][textarea rows="2"]. [select value="Denies suicidal ideation|Endorses suicidal ideation without intent|Endorses suicidal ideation with intent |"][textarea rows="2"]. [select value="Denies homicidal ideation|Endorses homicidal ideation toward |"][textarea rows="1"].
Perceptions: [select name="VH" value="Denies visual hallucinations|Reports visual hallucinations|No report of visual hallucinations"]. [select name="AH" value="Denies auditory hallucinations|Reports auditory hallucinations|No report of auditory hallucinations"]. [select name="illusions" value="Does not endorse illusions|Endorses misperception of environmental stimuli"].[checkbox name="hallucinations" value=" No evidence or report of tactile, olfactory or other types of hallucinations|Endorses tactile hallucinations|Endorses olfactory hallucinations|Endorses XX|denies depersonalization or derealization"] [checkbox name="internalstimuli" value="Does not appear to be responding to internal stimuli during interview. |Appears to be responding to internal stimuli during interview."]
Sensorium:[select value="alert and oriented to |disoriented to |"][select value="person, place, and time|"][textarea rows="1"].
Memory:[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"].
Attention/Concentration: [select value="attention span and concentration are adequate|difficulty with attention span and concentration are evidenced as "][textarea rows="2"].
Fund of knowledge: [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"].
Intellectual Functioning: [checkbox value="estimated to be average|unimpaired|impaired"].
Insight/Judgement: judgment concerning everyday activities is [select value="good|fair|poor|impaired|"][textarea rows="1"]. Insight concerning psychiatric condition is [select value="good|fair|poor|impaired|"][textarea rows="1"].

Mental Status Exam
Appearance: , appearing chronological age, .
Attitude/Behavior: eye contact.
Motor activity: .
Gait/Station: .
Speech: .
Language: ; vocabulary
Stilted speech- Sentences may be stilted or vague. Speech characterized by the use of words or phrases that are flowery, excessive, and pompous,e.g.The attorney comported himself indecorously.
Thought process: additional descriptors. .
Thought content: .. . . .
Perceptions: . . .
Sensorium:.
Memory:additional information about memory.
Attention/Concentration: .
Fund of knowledge: .
Intellectual Functioning: .
Insight/Judgement: judgment concerning everyday activities is . Insight concerning psychiatric condition is .

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