Preview

Mental Status Examination

Powerful Essays
Open Document
Open Document
1483 Words
Grammar
Grammar
Plagiarism
Plagiarism
Writing
Writing
Score
Score
Mental Status Examination
Importance of Case History Taking and Mental Status Examination
Case history is the record of patient’s life. The history is a patient’s life story told to the psychiatrist in the patient’s own words from his or her own point o view. It allows the psychiatrist to understand the patient and also helps in prognosis of the case. The history also includes information about the patient obtain from other sources such as parents or spouse. Getting the comprehensive history from a patient or from other sources is essential. Making a correct diagnosis and formulating a specific and effective treatment plan.
The assessment of a patient who may have a psychiatric disorder has several stages. It is needed to decide whether there is a disorder and if so of what kind, whether the patient is disabled and if so in what way, whether there is danger to the patient or to others, and what sort of person has become ill and what are his social circumstances.
To make their decisions, a detailed history taking, mental status examination and physical examination are needed.
A scheme for history taking; * Name, Age & Address of the Patient * Name of the Informant and their relationship to the Patient * History of Present Condition * Family History * Personal History * Past Illness * Personality * Use of Drugs, Alcohol, Tobacco etc.
Present Condition: - Symptoms with duration and mode of onset of each, the tie relations between symptoms and any physical disorder, or psychological or social problems, the nature and duration of any impairment, disability and handicap, any treatment received.
Family History: - Parents’ age now or at death, if dead, cause of death, health, occupation, personality, quality of relationship with patient.
Siblings names, ages, marital status, occupation, personality, psychiatric illness and quality of relationship with patient
Social position of family
Atmosphere in the home Any disorders in the family including

You May Also Find These Documents Helpful

  • Better Essays

    Case Study: Jay W.

    • 1722 Words
    • 7 Pages

    Sources of Information: Interview with the patient, Jay W. and his parents, Don and Beth W.…

    • 1722 Words
    • 7 Pages
    Better Essays
  • Satisfactory Essays

    2) the doctors notes and diagnosis and treatment information. 3) laboratory test results. 4) family medical history.…

    • 784 Words
    • 4 Pages
    Satisfactory Essays
  • Good Essays

    Hcr 220 Week 3 Assignment

    • 899 Words
    • 4 Pages

    During the new patient intake process, the patient comes to the office for the visit. Upon arrival the patient is given multiple forms to fill out. Medical History is important in understanding about a patient. It is important that physicians have access to a patient’s most recent medical history. A patient’s medical history may include personal medical history, family medical history, social history, or any medications or therapies currently used. Social history contains personal lifestyles choices, such as smoking, exercise or alcohol use. Patients are also asked to complete patient information forms. Patient…

    • 899 Words
    • 4 Pages
    Good Essays
  • Good Essays

    If the first two don’t provide you with the needed information you could ask resident’s family, friends, doctor or other professionals who have worked with the individual.…

    • 1208 Words
    • 5 Pages
    Good Essays
  • Satisfactory Essays

    Human behavior is complex and extremely variable among people. Some conducts of acting in the world are exposed by the population on a regular basis and seem to be well adjusted for functioning well in certain situations. Over time, understanding of and explanations for psychological disorders have gone through several significant changes. The primary statement of the medical mode is that mental, like physical, illnesses are best diagnosis and treated as medical illnesses. Psychiatry is a division of medicine, so it is not a coincidence that terms such as illness, diagnosis, and therapy or treatment are used in the context of psychological disorders.…

    • 103 Words
    • 1 Page
    Satisfactory Essays
  • Good Essays

    Assignment 401 Level 4

    • 949 Words
    • 3 Pages

    This assignment will analyse and explain initial and diagnostic assessment; explaining my own role, and how these assessments are included in my current working practices. Generally the research of ‘Gravells and Thompson’ is used. The internet has been a good source of information, which has helped expand on the subject.…

    • 949 Words
    • 3 Pages
    Good Essays
  • Good Essays

    With information obtained from previous steps, clinicians sometimes need to determine if hospitalization is the necessary procedure in helping clients with depressive disorders. Clinician need to determine the appropriate level of care (hospitalization, IOP, OP, etc.) that is most suitable for individual clients with depressive disorders.…

    • 441 Words
    • 2 Pages
    Good Essays
  • Good Essays

    In this assignment, you will be completing a comprehensive health screening and history on a young adult. To complete this assignment, do the following:…

    • 266 Words
    • 2 Pages
    Good Essays
  • Better Essays

    References: Lloyd, H., & Craig. S. (2007). A guide to taking a patient’s history. Nursing Standard,…

    • 1230 Words
    • 5 Pages
    Better Essays
  • Powerful Essays

    1) Various needs that would be considered when planning an individuals end of life care;…

    • 3023 Words
    • 13 Pages
    Powerful Essays
  • Powerful Essays

    Assessment and Nurses

    • 3002 Words
    • 13 Pages

    Assessment requires looking at the patient holistically and establishing what the patient was like before being admitted and what they are like now. If there is any change between the two, then the cause of this change must be identified. Once this is established, a detailed plan can be derived to tackle the actual problem and potential problems which may arise as a result. Assessment is important because it views the person as an individual (Barrett, Wilson and Woollands, 2009).The consequences of wrongly assessing a patient are that at the planning stage, care may be tailored incorrectly to their gender, religion and other factors which are paramount to that individual. This will in turn affect the way care is implemented. An individual’s culture, values and beliefs are highly influential in establishing what the carer may do for them and what they prefer to do themselves (Baldwin, Longhurst, Smith, et al, 2003).Information collected may be objective or subjective. Objective data is measurable and verifiable whereas subjective data is determined by the individual in order to understand their experience (Long, Phipps and Cassmeyer, 1995).In order to…

    • 3002 Words
    • 13 Pages
    Powerful Essays
  • Best Essays

    Care Plan

    • 2296 Words
    • 10 Pages

    When John arrived on the unit by Gardaí escort he was extremely paranoid and agitated. Initially he was seen by the duty doctor who conducted the assessment (appendix “A”). The assessment took place on the unit, my preceptor and myself were present. Throughout John remained guarded and uncooperative, it was difficult for the doctor to gather information from him. This is evident in the recovery care plan section as John would not engage or answer any more questions. Assessment is the decision making process, based upon the gathering of relevant information, using a formal set of ethical principles, that contributes to an overall estimation of a person and his circumstances (Arnold & Boggs, 2007).…

    • 2296 Words
    • 10 Pages
    Best Essays
  • Good Essays

    This implies that the nursing approach to health care is holistic, and assessments should reflect the whole person and their circumstances. The nurse should consider Abduls physical, emotional, spiritual, social and intellectual needs when making the assessment (UK Department of Health, 2016). Information will be collected about his health, which identifies the problems in order for solutions to be planned and implemented in line with his preferences (Loveday, 2012). For the appropriate care to begin, a nursing model of assessment has to be done, and this model needs to be holistic in all aspects of Abduls needs. Therefore, attention needs to be paid to his biological, psychological and social…

    • 709 Words
    • 3 Pages
    Good Essays
  • Good Essays

    medical law project

    • 1027 Words
    • 5 Pages

    1. Under HIPAA, are you legally allowed to view this patient’s medical information? Why or why not?…

    • 1027 Words
    • 5 Pages
    Good Essays
  • Powerful Essays

    Assessment is essential because the health care professionals need to know the physical, social, psychological, and cultural aspect of the patient’s life Wolters et al. (2008). An assessment is done to obtain information to create a detailed history about the patient, and to distinguish problems and to create a…

    • 22424 Words
    • 90 Pages
    Powerful Essays