Med Student:

Patient ID: What is your name? What would you like to be called?
Hold/Reason for Admission: 5150/5250/5270 for DTS/DTO/GD. Date, location, Riese

Date:
Time:

SUBJECTIVE:
How did you end up here? Your chart says this- is this true?
Current episode- Onset, Duration, Characterize, Alleviate/Aggravate, Radiation, Temporal. Impairment
in fxn
Baseline of mental health
DDx
Some patients say they experience ____- has this ever happened to you?
Mood swings- more intense than others? Highs, lows- how do they feel?
o How many, how long, what happens, using any substances at the time, given any
meds/hospitalized?
Manic- Bipolar
D- Distractibility
I- Indiscretion (risky)
G- Grandiosity/Self Esteemrate self esteem out of 10?
Can you do things that
others cannot?
F- Flight of Ideas/Racing
thoughts
A- Activity/Agitation
S- Sleep s/Insomniaenergy/10? Ever have so
much energy you feel you
dont need sleep?
T- Talkative/Pressured Speechanyone ever told you youre
talking too fast for them?

Depressive- Bipolar, MDD

Psychotic- Schizo, delusional
Depressed mood
Positive Sx
o
Hallucinations- Aud,
S- Sleep s
Visual
I- Interest loss (anhedonia)
o
Delusions- Grandeur,
G- Guilt, Worthlessness
Paranoid, Reference- do
E- Energy
you feel like people are
C- Concentration loss
watching you/talking
A- Appetite/Weight
about you/etc?
P- Psychomotor activity
o
Bizarre Behavior
S- Suicidal Idea (SADPERSONS)
o
Disorganization
o
M, >60 YO, prev attmpt, Negative Sx
substance abuse, rational
o
Anhedonia
thinking loss, FH suicide,
o
Affect flat
plan, no support, sickness
o
Alogia ( speech)
o
Avolition (apathy)
o
Attention Poor

Other
Anxiety- GAD, Panic Attack,
Specific phobia, OCD, PTSD
Personality
Substance
Cognitive (dementia, delirium)
Peds- MR
Dissociative
Somatiform, Factitious
Impulse Control
Eating, Sleep, Sexual

Past Psych Hx
Other Dx: Have you ever been diagnosed with a mental illness? Have you ever seen a
psychiatrist/psychologist?
Mood/Hurt Self, Others/Suicide:
Psych Hosp: Where are we? Have you ever been in a place like this before? How many times?
When/where/why?
Legal Hx: Have you ever been in trouble with the law? DUI, etc?
FH Psych: Does anyone in your family have any mental illnesses? Anxiety, Depression, etc?
Meds
Have you ever been on any (psychiatric) medications? Do any of these sound familiar- Lithium,
Valproate/Depakote, Risperidone, olanzapine/zyprexa, fluoxetine/prozac, sertraline/Zoloft,
paroxetine/paxil, Ritalin/methylphenidate?
OTC NSAIDS? Vitamins? Supplements?
PMH: Seizures? Trauma/TBI/unconscious? Asthma?
PSH:
Allergies:
FH:
Social Hx
Home: Where do you live? Where did you grow up? Married/kids? Somewhere to go when you leave here?
Education: Highest grade- HS?
Employment: What do you do for work? How do you support yourself? Military, disability, SS?
Activities
Drugs
o Cigarettes, marijuana? Alcohol? Cocaine, ecstasy, crystal meth, heroine, rx pills (methadone, BZs)?
o How old when started? Last time? How much? How often? Longest time sober? CAGE

o How does it make you feel? Ever make you see/hear things? Why did you start/stop?
o Every gotten in trouble because of it- blacked out, shakes, fights, legal problems (DUI)
Safety: Has anything really bad every happened to you- abuse?
Spirituality

OBJECTIVE:
Mental Status Exam

Appearance

Behavior

Attitude: Cooperative, calm | Charming, seductive, attentive, eager to please | Angry, agitated,
intimidating, intrusive, hostile | Distant, Distracted | Entitled, controlling, uncooperative, critical, childish
Eye contact, level of consciousness (lethargy, sleepy/drowsy, stuporous, alert)
Tremors, fidgeting, restlessness/anxious, slumped

Motor
Speech
Language
Mood
Affect
Thought Process
Thought Content

Perception

Insight
Judgment

Appears stated age, attire, hygiene/grooming, weight. Bruises, cuts (self-harm)

Rate (pressured, fast, slow), Amount (hyperverbal), Rhythm, Tone (monotone), Pragmatics (slurring,
stammering), Volume
Receptive
Expressive: latency in response
How do you feel right now? What is your mood? Scale of 1-10?
Patients description of how they feel
Sad, Depressed, Guilty, apathetic | Angry, irritable, anxious, suspicious, paranoid | Elevated, energetic
Examiners observation of patients current emotional expression
Range (expansive/full/blunted/flat), congruent/incongruent, mobility (labile, normal, constricted)
Logical, linear & goal directed, circumstantiality, tangentiality, loosening of associations, flight of ideas
Delusions
o
Grandiose, Persecutory/paranoid, bizarre (absurd, implausible, false beliefs)
o
Thought broadcasting/insertion/withdrawal, erotomatic
Obsessions, Persistent thoughts
Suicidal/Homicidal ideation, ruminations (worry that focuses on bad feelings from past)
Hallucinations
o
Auditory, Visual, Tactile, Olfactory? Responding to internal stimuli (talking to self, staring at
something in room)
Illusions
What do you think is going on with you? Why do you think you are here? Do you think you are ill/have a
mental problem?
Impaired/poor/intact/fair. Is patient aware of what is going on/know he has a problem?
What would you do if you smelled smoke in a crowded movie theater?
When you leave this place, do you have a place to go? Do you need help finding a place?
Impaired/poor/intact/fair. Can patient make good decisions- hold job, attend appointments, etc?

Mini Mental: Score ____/30. Not as important, mostly just

Temporal
What year/season/month/date/day of
Orientat.
week?
Spatial Orient.
What country/state/city/building/floor?
Registration

Repeat and Remember: Car, Ball, Man

Attn & Calc

Recall

Spell WORLD. Now backwards

(DLROW)
What were the 3 words?

Language

Name these objects: Watch, Pen

Repeat: No ifs, ands, or buts
Take this paper with your R hand, fold
it in half, and give it to me
Write a sentence that makes sense.

Visuospatial

Read and do what this says (close

your eyes)
Copy this diagram

do orientation
____/
5
____/
5
____/
3
____/
5
____/
3
____/
2
____/
1
____/
3
____/
1
____/
1
____/
1

ASSESSMENT- 1-2 lines of most pertinent information

Diagnosis- Be broad (NOS) initially. What do you need to rule out?

Medical Necessity- DTS, DTO, GD

PLAN
Legal Status- current hold, keep it?
Medications- continue, change, monitor SE, check blood levels
Discharge Plan place to stay after, contact family, another facility, work with social worker