This document contains a worksheet for conducting a brief mental status examination of a patient. It includes sections to document the patient's appearance, attitude, motor activity, speech, mood and affect, thought process, thought content, perception, orientation, memory, concentration, abstract thinking ability, judgment, insight, role and relationships. The examiner is asked to note any abnormalities observed in each area and provide a summary of significant findings along with 3 priority nursing diagnoses using the P-E-S format.
This document contains a worksheet for conducting a brief mental status examination of a patient. It includes sections to document the patient's appearance, attitude, motor activity, speech, mood and affect, thought process, thought content, perception, orientation, memory, concentration, abstract thinking ability, judgment, insight, role and relationships. The examiner is asked to note any abnormalities observed in each area and provide a summary of significant findings along with 3 priority nursing diagnoses using the P-E-S format.
This document contains a worksheet for conducting a brief mental status examination of a patient. It includes sections to document the patient's appearance, attitude, motor activity, speech, mood and affect, thought process, thought content, perception, orientation, memory, concentration, abstract thinking ability, judgment, insight, role and relationships. The examiner is asked to note any abnormalities observed in each area and provide a summary of significant findings along with 3 priority nursing diagnoses using the P-E-S format.
This document contains a worksheet for conducting a brief mental status examination of a patient. It includes sections to document the patient's appearance, attitude, motor activity, speech, mood and affect, thought process, thought content, perception, orientation, memory, concentration, abstract thinking ability, judgment, insight, role and relationships. The examiner is asked to note any abnormalities observed in each area and provide a summary of significant findings along with 3 priority nursing diagnoses using the P-E-S format.
Nursing Department NCM 117 (Lecture)- Care of Clients with Maladaptive Patterns of Behavior (Acute or Chronic) Worksheet No. 1 BRIEF MENTAL STATUS EXAMINATION
Name of Patient: __________________________________ Age: ________ Civil Status: ______________
Appearance ☐Casual dress, normal grooming and hygiene
☐Other (describe):
Attitude ☐Calm and cooperative (describe)
☐Uncooperative (describe)
☐Hostile (describe)
☐Apathetic (describe)
☐Suspicious (describe)
Motor Activity ☐No unusual movements or psychomotor changes
☐Other (describe):
Speech ☐Normal rate, tone, volume, and without pressure
☐Other (describe): UNIVERSITY OF SAN JOSE- RECOLETOS School of Allied Medical Sciences Nursing Department Mood and Affect MOOD: AFFECT: ☐Euthymic ☐Congruent ☐Irritable ☐Blunted ☐Elated ☐Flat ☐Grandiose ☐Inappropriate ☐Anxious ☐Depressed Thought process ☐Goal- directed and logical ☐Other (describe):
Thought content ☐Delusion (specify and describe):
☐Phobia (describe):
☐Obsession (describe):
☐Magical thinking (describe):
☐Other (describe):
SUICIDAL TENDENCY HOMICIDAL TENDENCY
Ideation: ☐Yes ☐No Ideation: ☐Yes ☐No Plan: ☐Yes ☐No Plan: ☐Yes ☐No If yes, describe: If yes, describe:
Means: ☐Yes ☐No Means: ☐Yes ☐No
If yes, describe: If yes, describe:
Perception ☐Hallucination (Specify type and describe):
☐Illusion (describe):
☐No alterations noted
Orientation
Memory Short- term memory:
☐Intact ☐Impaired UNIVERSITY OF SAN JOSE- RECOLETOS School of Allied Medical Sciences Nursing Department Long- term memory ☐Intact ☐Impaired
☐Literal interpretation noted (Concrete thinking only) Judgment ☐Good ☐Fair ☐Poor Insight ☐Good ☐Fair ☐Poor Role and Relationship Role at: Home:
Work/School:
Relationship with: Parents:
Siblings:
Relatives:
Neighbors:
Peer:
Summary of Significant Findings:
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ UNIVERSITY OF SAN JOSE- RECOLETOS School of Allied Medical Sciences Nursing Department Formulate three (3) priority nursing diagnoses using the P-E-S format. 1. 2. 3. Submitted by (Write names of group members):
The Dissociation Made Simple Flipchart: A Visual Guide for Clinicians Working with Dissociative Clients--Addresses dissociation as a symptom of CPTSD, OSDD, DID, and trauma
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