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.
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.