National

Center for Mental Health

ER 2. Biperiden 2mg/tab
- all patients: vital signs Sig. Uminom ng isang tablet sa isang araw kapag
- for admission: PE+Neuro nakararanas ng paninigas, paglalaway, o pagrorobot
- census *usually #5
- combo forms *usually OD PRN for EPS

ACIS 3. Diphenhydramine 50mg/cap
- readmission: PE+Neuro Sig. Uminom ng isang kapsula sa gabi kapag hirap
st
- 1 admission: Hx+MSE, PE+neuro makatulog
- abstract (before 8am): General data, brief *usually #5
history, course in the ward, PE *usually ODHS PRN for poor sleep
- census (before 8am)
- combo forms 4. Fluphenamine decanoate 250mg/ml
*check heading of paper if for PE+Neuro, Hx+MSE, or *just #1
Abstract Sig. 1cc via IM with strict BP precaution
*Hx+MSE and PE+Neuro can be back to back
*Abstract should be written in 1 page 5. Haloperidol decanoate 5mg/cc
*All Hx+MSE and PE+Neuro papers should be signed *just #1
by the JI, relative/informant, then the Doctor. Once Sig. 1cc via IM with strict BP precaution
signed by the doctor, insert the paper in the
patient’s chart according to the page code found at 6. Chlorpromazine 100 or 200mg /tab
the upper right hand corner. *OPS: usually #30

OPS 7. Divalproex Na 250mg/tab
- SOAP, prescriptions 8. Lithium carbonate 450mg/tab
9. Quetiapine 25/100/200/300mg /tab
Pav 1 10. Olanzapine 10mg/tab
- 2 Hx, MSE, PE, Neuro 11. Clozapine 25/100mg /tab
- 4 MSE 12. Cabamazepine 20mg/tab
*submitted at the end of the NCMH rotation in A4 13. Fluoxetine 20mg/tab
paper, any sans serif font 14. Sertraline 50mg/tab
15. Escitalopram 10/20mg /tab
MEDICATIONS 16. Haloperidol 5/10/20mg /tab
*duplicate prescription (cabon paper is lyf)
*Sig. is in Filipino COMBO FORM
ST
*be aware of the dosage they put. If the only available 1 PAGE: name of px, address, date of admission, dx
tab is 2mg and they put 1mg, it means you have to put (copy from latest SOAP of progress notes), medications
kalahating tableta in the sig (copy latest in doctor’s orders), follow up date (copy
*Pav 1 format: Risperidone tablet 2mg #_ from latest SOAP of progress notes or ask resident)
*ER/ACIS format: Risperidone 2mg/tab #_ PRESCRIPTION: check latest in doctor’s orders
ST
1 SHORT BOND PAGE: write prescription with Filipino
1. Risperidone 2mg/tab Sig.
*if ODT: ABSTRACT: (check attached template)
Risperidone 2mg/tab ODT
Sig. 1 tab SL Abstract, Hx, MSE, PE, Neuro, OPS SOAP: check attached
*if 1-2mg BID: templates
Sig. Uminom ng kalahating tableta sa umaga at isang
tableta sa gabi
*if 2-4mg BID:
Sig. Uminom ng isang tableta sa umaga at isang tableta
sa gabi
*if 2-1-2mg TID:
Sig. Uminom ng isang tableta sa umaga, kalahating
tableta sa tanghali, at isang tableta sa gabi
*Risperidone 2mg/tab ODT is different from Risperidone
2mg/tab OD, BID, TID – use separate prescription for
ODT

HISTORY

General data Name Occupation
Age Birthdate
Sex Birthplace
Civil Status Current Residence
Religion Brought in by:
st
Nationality 1 or Readmission
Educational Attainment Date of admission
This is the case of (name), a (age)-year old (sex), (CS), (religion), (nationality), reached/graduated (educ
attain), (working as a (occu)/unemployed), born on (bdate) in (bplace), currently residing at (residence),
brought in by (bantay) in our center for (the first time/readmission) on (date of ad).
Presenting According to informant: “______________________________” (ex. “nagwawala”)
Complaint/s “______________________________”
“______________________________”
According to patient: “________________________________” (ex. “hindi ko po alam” or no verbal output)
Informant Name Occupation
Age (Does not live/lives) with patient since ____
Relation to patient
% Reliability
Onset Year of onset of psychiatric illness
History of (how we usually do history; use separate paper para bibo kid)
present Illness
Past Medical and Vaccination Psychiatric:
Psychiatric Childhood illnesses Date of previous episode
History HPN (onset, medications, dose) Date of last admission
PTB (onset, medications, dose) Hospital
BA (onset, medications, dose) Symptoms
Allergies (food and drugs) Treatment
Surgeries Compliance
Blood transfusions
Hospitalizations
Accidents
Substance Type Cigarette Alcohol (specify Marijuana Methamphetamine
history which beer or hard)
Amount
Dosage
Last supply/
session
Frequency
Duration
Onset
Longest without
supply
Symptoms without
vice
Family History Member Age Diseases/Cause of death
Father
Mother
Sibling/s (specify
sex and order)
or
Other/s (specify if
p/maternal)
Obstetric and Age at menarche
Gynecologic Regularity, interval
History Duration
Amount of flow
Premenstrual Symptoms
Last Menstrual Period

 Previous Menstrual Period
Age at menopause
Symptoms of menopause
Use of Hormonal Replacement
Gravidity
Parity
Manner of delivery
Birth control methods
Past Personal Prenatal Planned/unplanned
History and Wanted/unwanted
(Anamnesis) perinatal Full term/premature
Vaginal/caesarian
Drugs taken
Complications
Defects at birth
Early Infant and mother relationship
childhood Feeding
(1 month to With/without delay in developmental milestones
3 years) Caretakers
Usual behavior
Middle Preschool and elementary experiences (bullied or not)
childhood Caregivers
(4-11 years) Friends (neighbors/school)
Usual behavior (silent type/loud/etc)
Sports/orgs/clubs
Hobbies/Social activities
Late Onset of puberty
childhood/ Academic achievements
adolescence School experiences (bullied or not)
(12-21 Caregivers
years) Friends (neighbors/school)
Usual behavior
Sports/orgs/clubs
Hobbies/Social activities
Romantic experience
Work experience
Vices
Young/ Friends
middle/ late Usual behavior
adulthood Sports/orgs/clubs
Hobbies/Social activities
Romantic experience
Work experience
Vices
Legal experience
Past Social Education
History Sexual Sexually active or not
history Problems in sex
Age and manner of acquisition of sexual knowledge, identity, orientation
First sexual experience
Sex in romantic relationship or casual
Legal Reason for imprisonment
history Date
Duration
Other details
Premorbid According to (relation of informant to patient): (ex. “mabait naman” “masayahin” “mahiyain” “torpe”)
personality

MENTAL STATUS EXAMINATION

Parameters Sample questions
General Appearance Behavior Attitude
(Appearance, Height: Mannerisms: cooperative / hostile / open /
Behavior, Built: light / medium / heavy Gestures: secretive / suspicious / apathetic /
Attitude) Grooming: well / poorly kempt Expression: focused / defensive
Clothes: Eye contact/gaze:
Hair: Ability to follow commands/requests:
Nails: clean / dirty / short / long Compulsions: calm / restless /
Posture: agitated / combative
Mood and Kamusta na ang pakiramdam mo ngayon? happy / sad / angry / depressed
Affect How does he/she show his/her feelings? Euthymic(normal) / constricted / blunted / flat / expansive
Speech Quantity: Rate: Volume/Tone: Fluency/Rhythm:
talkative fast loud slurred
spontaneous slow soft clear
expansive normal monotone appropriate
paucity pressured weak hesitant
poverty strong good articulation
normoproductive normal pitch aphasic
audible stuttering
Thinking Logic, relevance, organization, flow, coherence
(form, Blocking – abrupt cessation of speaking
content) Circumstantiality – too much explanations and extra details
Clanging – associations based on punning or rhyming
Echolalia – meaningless repetition of another person’s spoken words
Flight of ideas – racing thoughts
Ideas of reference – interpretation of unrelated events as having personal reference or significance
Loosening of associations – illogical transition between topics
Neologisms – creating new words
Perserverate – repeat or prolong an action, thought, or utterance after the stimulus has ceased
Tangentiality – response that wanders from one topic of discussion to other topics in association
Thought insertion – delusion that patient thinks thoughts of other persons are inserted into their minds
Thought withdrawal – delusion that thoughts have been taken out of patient’s mind
Sensorium Alertness: vigilant / alert / drowsy / lethargic / stupurous / asleep / fluctuating
and Orientation (time, place, person): Anong pangalan mo? Nasaan ka ngayon? Umaga, hapon, gabi?
Cognition Concentration: (observe)
Memory (immediate, recent, long term): lapis, papel, bola -ask to repeat, ask after 5 mins; pangalan ng asawa?
kailan kinasal?
Calculations: 100 – 7 = ? -subtract 5 times
Fund of knowledge: Sino presidente natin ngayon? Sino bise presidente? Magbigay ng 5 pangalan ng mga
naging presidente. Ano ang ibig sabihin ng KKK?
Abstract thinking: Sa lapis, krayola, at damit, alin ang naiiba? Bakit?
Insight Alam mo ba kung bakit ka nandito? Ano kayang dahilan kung bakit ka dinala rito?
Complete denial of illness
Slight awareness of being sick and needing help but denying it at the same time.
Awareness of being sick but blaming it on others, external factors, or medical or unknown organic factors.
Intellectual insight: Admission of illness and recognition that symptoms or failures in social adjustment are due
to irrational feelings or disturbances, without applying that knowledge to future experiences.
True emotional insight: Emotional awareness of the motives and feelings within and of the underlying meaning
of symptoms, whether the awareness leads to changes in personality, and future behavior; openness to new
ideas and concepts about self and important people in the person’s life.
Judgment Anong gagawin mo kung nakita mong nahulong ng tao sa harap mo ang pitaka niya na puno ng pera?
Anong gagawin mo kung nasa sinehan ka na puno ng tao at nakaamoy ka ng usok?

PHYSICAL EXAM
(De kahon)

GENERAL: conscious, coherent, not in cardiorespiratory distress with the following vital signs:
o o
BP: ____ mmHg RR: ____ cpm PR: ____ bpm T : ____ C
HEENT: symmetric head, normocephalic, 2-3mm pupils equally reactive to light, pink palpebral conjunctiva, no nasoaural
discharge, no tonsillopharyngeal congestion, no cervicolymphadenopathy
CHEST & LUNGS: symmetrical chest expansion, no lagging, no retractions, clear breath sounds
HEART: adynamic precordium, normal rate, regular rhythm, no murmurs
ABDOMEN: flat, normoactive bowel sounds, soft, nontender
EXTREMITIES: no gross deformities, no cyanosis, no edema
SKIN: no active dermatoses (but usually there are open wounds, abrasions, healed scars, or tattoos so please take note of these)

NEURO EXAM
GENERAL: conscious, coherent, oriented to time, place, and person
CN I: not assessed
II: 2-3mm pupils equally reactive to light
III, IV,VI: intact extraocular muscles
V: can clench jaw
VII: no facial asymmetry
VIII: can hear sounds bilaterally
IX, X: uvula at midline
XI: can shrug shoulders
XII: tongue at midline upon protrusion

Motor:
5/5 5/5
5/5 5/5

Sensory:
100% 100%
100% 100%

DTR:
++ ++
++ ++

ABSTRACT

PAVILIONS
1. General data:
This is a case of (initials), a (age)-year old (sex), (civil status), (nationality), (religion), reached/finished (educational
attainment), employed as (current employment), born on (birthdate) in (birthplace), currently residing at (current
residence), brought in by (?) admitted (for the first time? readmitted) at our center on (admission).
2. Brief background history:
st
- 1 admission
The patient was apparently well until ___ PTA when he/she was noticed with ___. Symptoms persisted until ___ PTA
when he/she became physically/verbally assaultive, prompting consult and subsequent admission.
- for substance use disorder
The patient has been a known (methamphetamine/alcoholic beverage/cannabinoid user) since ___ (see HPI).
- for vagrants
As per social case report, ___ (see HPI)
- Readmission:
The patient has been mentally ill since ___ with previous admission in our center, last being ___. He/she was
maintained on ____, taken with (good/fair/poor) compliance. He (remained/been) (semifunctional/nonfunctional) at
home with on and off tolerated relapses.
___ PTA, he had ___ (see HPI). Persistence of symptoms prompted consult and readmission.
3. Course in the ward:
- ACIS admission
The patient was admitted in ACIS (1/3), ordered with labs/CXR, and was started on medications. He/she, however,
remained unimproved, thus, was transferred to Pavilion (1/3) for continuation of psychiatric treatment. (May add:
He/she had been referred to Pavilion 7 due to ___, which was managed accordingly)
- Direct admission (Pavilion 1/3)
The patient was admitted in Pavilion (I/III), ordered with labs/CXR, and was started on medications. (May add: He/she
had been referred to Pavilion 7 due to ___, which was managed accordingly).
Currently, the patient was behaviorally manageable and was deemed fit for discharge.
- From Pavilion 7 to Pavilion 1/3
The patient was referred and admitted in Pavilion 7 due to (see ER referral form/progress notes). He/She was
transferred to Pavilion (1/3) for continuation of psychiatric treatment. (May add: He/she had been referred to Pavilion
7 due to ___, which was managed accordingly).
Currently, the patient was behaviorally manageable and was deemed fit for discharge.
4. Physical Examination:
Vital signs: BP= , HR= , RR= , T=
Essentially normal at the time of examination. (Indicate pertinent PE finding/s if there are any)

ACIS 1/3
1. General data:
This is a case of (initials), a (age)-year old (sex), (civil status), (nationality), (religion), born on (birthdate) in (birthplace),
currently residing at (current residence), admitted (for the first time?) at our center on (admission).
2. Brief history:
- Readmission
The patient ha been mentally ill since ___ with previous admission in our center, last being ___. He/she was maintained
on ____. He/she had on and off tolerated relapses.
st
- 1 admission
The patient was apparently well until ___ PTA when he/she was noticed with ___. Symptoms persisted until ___ PTA
when he/she became physically/verbally assaultive, prompting consult and subsequent admission.
3. Course in the ward:
The patient has been admitted in the ER due to ___. He/she was transferred to (ACIS1/3) where his/her treatment was
continued. He/She was ordered with labs and started with meds as follows: ___. He/she was put on restraints for ___
days.
- Transferred to Pav
He/she, however, thus was transferred to Pav___.
- Discharge
Currently, the patient was behaviorally manageable and was deemed fit for discharge.
4. Physical Exam (de kahon)

OPS SOAP
*use the consultation page, whatever space is available should be used

S> Came (alone or with?)
Sleep
Appetite
Work/functionality at home
Smoking
Alcoholic beverage
Compliance with meds
(Why they didn’t come on TCB date)
Other complaints

O> (well?) kempt
Conversant?
*Suicidal ideations
*Morbid/Homicidal ideations
*Irritability
*Depressive episodes
Racing thoughts
Racing thoughts
Hyperactivity
Hopelessness/worthlessness
Poor concentration
*important to ask, accdg to Dr. Quitos
- also ask additional questions that might be important for the diagnosis

A> Copy from previous assessment, check if improved/manageable/disturbed; include F code

P> Copy from previous prescription except if you feel there’s a change in dosage or meds depending on adverse effects
mentioned in S

*sign at lower right hand corner
























Sources:
Lecture Notes, Lea Pacis History trans, Trans from Fatima, examples from NCMH