Medical Transcription
Mental Health Exam
APPEARANCE
PHYSICAL CHARACTERISTICS: GROOMING, DRESS, PERSPIRATION, USE OF MAKE-UP, TATTOOS, HEIGHT, WEIGHT, NUTRITIONAL STATUS... DILATED PUPILS (DRUG INTOXICATION) & PINPOINT PUPILS (DRUG WITHDRAWAL) BEHAVIOR / PSYCHOMOTOR GAIT, POSTURE, GESTURES, SCANNING, EYE CONTACT, STEREOTYPIES SPEECH / LANGUAGE RATE, VOLUME, TONE EMOTION AFFECT (OUTWARD
EMOTIONAL EXPRESSION DURING INTERVIEW) MOOD (LONG RANGE
EMOTIONAL STATE -- REPORTED) COGNITIVE FUNCTIONS ORIENTATION: PERSON (WHO ARE YOU), PLACE (WHERE ARE YOU), TIME (WHAT IS TODAY'S DATE), SITUATION (WHY ARE YOU HERE) CONSCIOUSNESS: ALERT, CONFUSED, CLOUDED, STUPOROUS, UNCONSCIOUS, COMATOSE ATTENTION/CONCENTRATION: SERIAL 7'S, HOUSE & WORLD, DIGIT SPAN MEMORY: INTELLIGENCE: ACADEMIC PROBLEM SOLVING, PRACTICAL INTELLIGENCE, CREATIVE INTELLIGENCE (STERNBERG TRIARCHIC THEORY); OBSERVE LANGUAGE USE, DEFINITIONS, BASIC FUND QUESTIONS, INFER FROM EDUCATION AND OCCUPATIONAL STATUS, GENERAL INTERACTIONS... ABSTRACT REASONING: THOUGHT PROCESS: LOGICAL, CIRCUMSTANTIAL, LOOSE, TANGENTIAL, WORD SALAD CONTENT:
THEMES, PREOCCUPATIONS, DELUSIONS PERCEPTIONS ILLUSIONS: MISPERCEPTIONS OF REAL SENSORY EXPERIENCE HALLUCINATIONS:
NO SENSORY STIM, BUT THEY BELIEVE THERE IS JUDGEMENT/
INSIGHT |