Goal and Objectives: a. Gather clients data thoroughly; b. identify clients need as perform complete assessment; c. discuss clients present condition; d. construct a plan for client that are specific, measurable, attainable, realistic, and time bounded goal of care and interventions; e. formulate priority interventions or plan of care; f. implement the plan of care; g. conduct an evaluation if the plan of care have been met, partially or not met; h. emphasize the value of life, respect and privacy during the care of the patient A. Personal Data Name: Address: Age : Gender : Birth date: Birth Place Ordinal Rank: Nationality: Civil Status: Religion: Educational Attainment: Occupation: Fathers Name: Occupation: Mothers Name: Occupation: B. CLINICAL DATA Agency: Date of Admission: Came in due to: Attending Physician Diagnosis: Genogram (Family) The family genogram is a pictorial display of a person's family relationships and medical history
ANAMNESIS Informants
COURSE IN THE HOSPITAL
Mental Status Examination A. MENTAL STATUS EXAMINATION June 11, 2014 (Orientation Phase) I. PREEXAMINATION A. GENERAL APPEARANCE B. GENERAL MOBILITY -Posture & Gait: - Activity: ( ) Normoactive ( ) Psychomotor retardation ( ) Hyperactive ( ) Agitated - Facial Expression: C. BEHAVIOR: ( ) friendly ( ) impulsive ( ) angry ( ) embarrassed ( ) negativistic ( ) evasive ( ) seductive ( ) indifferent ( ) withdrawn D. NURSE-PATIENT INTERACTION ( ) cooperative ( ) initially ( ) uncooperative () all throughout Quality: ( ) warm ( ) distant ( ) dependent ( ) hostile ( ) suspicious ( ) talkative II STREAM OF TALK: A. CHARACTER () spontaneous ( ) deliberate ( ) pressure ( ) blocking B. ORGANIZATION OF TALK ( ) relevant ( ) loose of association ( ) tangentiality ( ) irrelevant ( ) flight of ideas ( ) neologism ( ) incorrect ( ) circumstantiality ( ) others ____ C. ACCESSIBILITY () good ( ) self-absorbed ( ) defensive ( ) fair ( ) mute ( ) inaccessibility III. EMOTIONAL STATE & REACTIONS: A. MOOD ( ) euthymic ( ) depression ( ) euphoria B. AFFECT ( ) appropriate ( ) inappropriate Quality: ( ) flat ( ) elated ( ) histrionic ( ) blunted ( ) labile ( ) angry ( ) hostile ( ) anxious others _______ Progress Notes C. DEPERSONALIZATION & DEREALIZATION ( ) present () absent
D. SUICIDAL HOMICIDIAL ESCAPE POTENTIAL
() present ( ) absent IV THOUGHT CONTROL: A. PERCEPTION ( ) present ( ) absent B. DELUSIONS ( ) present () absent C. IDEAS OF REFERENCE ( ) present () absent D. PREOCCUPATIONS & RUMINATIONS E. DEJAVU & JAMAIS VU ( ) present () absent V NEUROVEGETATIVE DYSFUNCTION: A. SLEEP B. APPETITE: C. DIURNAL VARIATION: D. WEIGHT E. LIBIDO VI GENERAL SENSORIUM & INTELLECTUAL STATUS: A. ORIENTATION: B. MEMORY: C. ATTENTION SPAN: ( ) good ( ) fair ( ) poor D. GENERAL INFORMATION E. ABSTRACT THINKING ABILITY E. JUDGEMENT & REASONING () unimpaired ( ) impaired VII - INSIGHT () unimpaired ( ) impaired VIII SUMMARY OF MENTAL STATUS EXAMINTATION: A. Disturbance in: () Presentation ( ) Insight ( ) Stream of talk () Neurovegetative Dysfuntion () Thought Control ( ) General Sensorium & Intellectual Status () Emotional state and reaction B. Diagnosis Category () Psychotic ( ) Non psychotic
C. DSM IV-TR Diagnosis
Axis 1- ___(Clinical Syndromes) Axis ii- ____ (Personality and development disorder) Axis iii- ___(Physical disorders and conditions) Axis 1V- ____(Psychosocial and Environmental problems) B. MENTAL STATUS EXAMINATION (Working Phase) DATE: June 12, 2014 I PREEXAMINATION A. GENERAL APPEARANCE Psychodynamics Definition of Diagnosis MEDICAL MANAGEMENT Drug Studies Diagnostics Nursing Care Plans Prognosis Health Teachings