Initial Patient Assessment & Mental Status Examination

Full name, sex, age, date of birth, address, marital status, family members names and ages.

Demographic Data

Date and time of admission, type of admission (voluntary or committed).

Admission Data

Current problems as perceived by the patient: stressors, difficulty coping, developmental issues, emergency behaviors, and family history.

Reason for Admission

Dates, inpatient/outpatient, reasons for and types of treatment, effectiveness, current medications, compliance, and medical problems.

Previous Psychiatric History

Amount, frequency, duration of past and present use of legal/illegal substances, date and time of last use.

Drug and Alcohol Use/Abuse

Sleep, intake, elimination, sexual activity, work, leisure, self-care, and hygiene.

Disturbances in Daily Living Patterns

Ethnicity, beliefs, practices, religious preferences.

Culture/Spirituality

Amount of contact, nature/quality of relationships, availability of support.

Support Systems

Type, condition, and appropriateness of clothing (for age, season, setting), grooming, cleanliness, physical condition, and posture.

General Appearance

covert, overt, verbal, or physical.

Expression of Anger

positive/unpleasant habits, shyness, withdrawal.

Social Skills

psychomotor retardation, agitation, restlessness, tics, tremors, hypervigilance, lack of activity.

Motor Activity

amount, rate, volume, pressure, mutism, slurring, or stuttering.

Speech Patterns

to time, place, and person; and level of consciousness.

Orientation

recent/remote, amnesia, blackouts, confabulation.

Memory

coherence, confusion, and vagueness.

Thought Clarity

blocking, circumstantiality, loose association, flight of ideas, preservation, tangential ideas, ambivalence, neologisms or 'word salad'.

Thought Process

helplessness, hopelessness, worthlessness, guilt, suicidal ideas/plans, suspiciousness, phobias, obsessions, compulsions, preoccupations, antisocial attitudes, blaming of others, poverty of content, or denial.

Thought Content

visual, auditory or other.

Hallucinations

of reference, influence, persecution, grandeur, religious, or somatic.

Delusions

Use of language and knowledge, abstract vs concrete thinking (proverbs), or calculations (serial sevens), educational level.

Intellectual Functioning

Anxiety level, elevated or depressed mood, labile, blunted or flat affect, or inappropriate affect; specific feelings expressed.

Affect/Mood

Degree of awareness of problems and their causes.

Insight

Soundness of problem solving and decisions.

Judgment

Degree of motivation for treatment.

Motivation