TEMPLATE: THE PSYCHIATRY EXAM

Here is a template that helps one document encounters with psychiatric overtones.  I included pertinent negatives that help prompt one to use the right terms.  These can be deleted during actual encounters.  Although I hear many express less enthusiasm for psychiatric emergencies, I believe that being able to systematically assess a patient’s psychiatric state goes a long way toward understanding the difficult patient encounter.

 

Arousal: Alert

Attentiveness: fully attentive

Appearance: well-dressed and well-groomed

Attitude: cooperative, not guarded

Activity: calm, not restless, no abnormal movements, good eye contact

Orientation: Fully oriented

Mood: euthymic, not dysphoric, euphoric, apathetic, anxious or angry

Affect: normal range, not restricted, flat, or labile

Verbal: nl expressive and receptive language function

Thought process: organized, goal-directed. Pt did not require redirection.

Thought content: no delusions, no suicidal/homicidal ideation

Perceptions: not responding to internal stimuli

Insight/Judgment: good insight, judgment appears to be good

 

 

References for this include Trzepacz’ excellent textbook, The Psychiatric Mental Status Examination.

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