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The psychiatric case note.

For CCR meeting


27 November 2007.

Chris Gale
Development.
1. Medicine & Neurology: history and
examination.
2. Phenomenology  detailed clinical
description.
3. Psychotherapy  developmental,
formulation.
4. UK (Maudsley)  manualised traditional
file.
5. Problem orientated medical notes.
6. Computerisation and consumer input.
Traditional (Maudsley)
assessment.
Referral
History Presenting complaint.
Past History
Family History
Developmental History
Social history
Mental State examination.
Physical examination.
Formulation
Diagnosis  Plan.
Referral/ Triage.
1. Who referred?
2. What are concerns?
1. Is there an issue of risk?
2. Is there an issue of urgency?
3. Who is the proposed patient?
4. How and when can they be seen?
History.

What are the compliants?


 Patient.
 Family / whanau
 Wider community.
When, where, what is associated,
exacerbating, relieving, attribution of
symptoms, how long.
Consequences:
 Disability
 Suffering.
System review.
System review.
Cardiovascular
Respiratory
Genito-urinary
Neurological
Endocrine
Psychiatric.
Psychiatric systems review.
Sleep
Energy
Appetite
 Weight gain or loss
Delusions & hallucinations.
Self-harm.
 Tedium vitae, neglect, self-harm (cutting, burning)
 Suicide ideation, plans, attempts.
Past history.
Medical
Surgical
Allergies
Current medications
Substances
 Past
 Current (Cut down Abstinent Guilt Eye opener)
Forensic.
Psychiatric Past History.
Previous episodes.
 When
 What were symptoms then.
 Treatment
 Medications.
 Psychotherapies.
 Attribution recovery | continuation symptoms.
Collateral
 Old notes
 Family
Family history.
Medical
Psychiatric.
 Relative’s experiences:
 Service (esp. adverse)
 Treatment (successful and adverse).
 Substances.
 Suicide.
Developmental I: the family
players.
Geno-
gram.
Age, job.
Support,
conflict.
Isolation
or
support
Developmental II: Life history.
Infancy
Early childhood.
Primary school
Secondary school
Training / University.
Work
Relationships.
Developmental III:
personality.
Usual (premorbid) personality.
Percieved strengths & weaknesses.
Hobbies, interests.
Methods of coping.
 Loss
 Stress
 Current situation.
What supports & strengths currently
accessible.
Socail.
Living.
 Who with
 Rent or own.
 Food, heating.
Financial
Legal
 Current charges.
 Care children
 Financial (IRD, debt, bankruptcy).
Substance abuse
 (in twice so will ask once)
[Physical examination.]
Nutrition (Height, weight. BMI)
Cardiorespiratory, (pulse, BP)
Circulation
Neurological
(abdominal and g-u very rarely, usually
referred).
Mental State Examination.
“BOTAMI”
Behavior
Orientation
Talk and Thought
Affect
Mood
Insight and Judgement.
Behaviour.
“Three As”.
Appearance
Activity.
 Specific comment extra-pyridoxal side-effects
“EPS”.
 Comment if responding non-apparent stimuli
(“NAS”) i.e.. Hallucinating.
Attitude
 Rapport.
Orientation.
Aware time, place, person.
Level of consciousness.
Bedside tests.
 MMSE
 Extensions (idiosyncratic list of tests).
 Clock face.
 Similarities and differences.
 Approximations.
 Verbal fluency.
 Fist-side-palm.
Repeat assessment at another time if
concerned organic (delirium workup first).
[Delirium workup]
Rule out correctable causes.
Detailed physical examination and
investigations as appropriate. Usual include:
 CBC, CXR, MSU.
 LFTs [VDRL, Hep C, HIV].
 Na, K, Urea, Creatinine
 Glucose
 ECG
 CT head (any history trauma, any neurological
signs).
Talk
Rate & Flow
 Normal, Staccato
 Laconic. Over inclusive
 Mute
Prosody
Thought
Form
 Organised
 Includes circumlocutory (does not lose goal)
 Disorganised (loss of goal)
 Loosening of associations  word salad.
 NB ‘flight of ideas’  manic mood
Content.
 Describe phenomena & themes.
Affect
Range
Mobility.
 Restricted  Labile
“affect is weather, mood is climate”.
Mood
Rich vocabulary mood states.
 Angry
 Sad
 Anxious
 Happy…
Technical terms.
 Hypomanic never involves psychotic symptoms.
 Dysphoria implies does not currently meet criteria
depression.
Insight
Comprehend
 Information you provide & other sources.
Cognitively process
 Impaired by defence mechanisms.
Communicate
 Choices to you.
[Defense mechanisms I]
High adaptive
 Anticipation, affiliation, altruism, humour,
self-assertion, self-observation,
sublimation, suppression
Compromise formation
 Displacement, dissociation,
intellectualisation, isolation of affect,
reaction formation, repression, undoing.
[Defense mech II]
Image distortion, minor
 Devaluation, idealising, omnipotence
Disavowal
 Denial, projection, rationalisation.
Image distortion, major
 Autistic fantasy, projective identification,
splitting (self image, others)
[Defense mech III]
Action
 Acting out, apathetic withdrawal, help-
rejection complaining, passive regression.
Defensive dysregulation
 Delusional projection, psychotic denial,
psychotic distortion.
Judgement
Ability to understand consequences
actions.
AND
Ability to take responsibility for actions.
Formulation (psychiatric)
1. Summary sentence presentation.
2. Predisposing factors
3. Precipitating factors
4. Perpetuating factors.
[Choice of model flows from problem]
Diagnosis
DSM Axes
1. Psychiatric syndrome
2. Personality
3. Medical condition
4. Social stressors
5. Level of function.
Plan.
Place of care
 Risk management (suicide, self harm, harm
others)
 Use inpatient, respite, MHA.
Biomedical
 Investigations.
 Medications
 ECT, light therapy.
Psychological
Social
 Risk management (money, child care etc).
 Functional assessment & rehabilitation.
Assessment Write up.
Traditionally
 5-6 sheets A4, or 2-4 pages typed.
 Plan followed opinion (driven by doctor).
 Risk loss previous knowledge.
Traditional note or letter.
Process of interview.
Content of interview
Assessment
Interventions
Ongoing plan.
Psychotherapy “process” note.
Dynamic
 Narrative.
 Defences and Transference
 Interpretations.
Structured.
 Plan / protocol session.
 Adherence / homework
 Process of session.
 Homework
 Plan next session.
Psychopharm progress note.
Process interview.
Symptoms including side-effects
Level of function
Focused mental state.
Relevant investigations.
Medication changes / current
medications.
Current records
Based on Problem orientated medical record
– Good medical record.
Case management model
 Negotiated with patient / client.
 Redundant recording:
 risk of contradiction.
 Risk Prevention Plan
 Advance directive
 Management plan.
 Risk being unread.
[Problem orientated medical
record]
Invented in 1970s.
Database (initial assessment &
investigations.
Problem list.
Plan.
[Problem orientated progress
notes.]
List of active problems.
For each problem “SOAP”
 Subjective
 Objective (MSE findings, outcome scales
etc).
 Assess
 Plan
Thank you