Day 6--Friday--Psychiatric Reports Quiz and SRE Quiz Today

client

Use ______, not patient

mentally deficient

—Lack of mental development.

disturbance

mentally deficient is a _______ in functioning

normal

In mental deficiency the individual NEVER had the potentialities for ______ mental growth and development.

mentally impaired

Any mental or psychological disorder (mental retardation, organic brain syndrome, emotional or mental illness) and associated learning disabilities.

developmentally disabled

referred to as mentally retarded.

Admission Note Contents

Mentally deficient client

• what kind of notes are used?

Mental Status Exam

a standard part of any psychiatric interview.

• It is a description of clinical observations of a patient's current emotional state and mental functioning

True

mentally disabled client reports inclue psychiatric eval vs psychological eval

• T or F

conference

Used to determine the treatment goal and track progress.

final treatment goal

Fully functional in society

developmentally disabled client

what kind of client might include a medical history, review of systems, release summary, and clinical record documentation system, which is equivalent to a treatment planning conference for a mentally deficient client?

Clinical record documentation system

the same as the treatment-planning conference for the mentally deficient clients but with more detail.

• what kind of system?

Clinical psychologist

Reports do NOT always contain a physical exam of the body systems or a list medications.

• who reports it?

motor skills

Clinical psychologist do list the client’s ability in _______ skills.

legal terms

Clincial Psychologists

These terms often are included in clients’ reports due to the clients’ many legal problems.

chemical abuse

Clinical Psychologists

• Clients may be seen for this type of abuse.

slang terms

Using these terms for drugs is appropriate to transcribe.

DSM-5-TR

________ diagnosis codes for the mentally disabled

ICD-10-CM

The ______ may be used for coding developmentally disabled clients—unless the psychiatrist prefers to use the DSM-5-TR coding system.

confidentiality and access

Psychiatric records often are more strict than other medical record with ________ and ________.

client

Psychiatric records may not even be accessed by the _______.

physician’s and client’s or guardian’s

Medical info is released only with the ______ and ______ or ______ signatures.

Records

_____ may be sent to a long-term care facility (nursing home).

Medical records

Thses records may be subpoenaed by the court system.

psyschiatric reports

Direct quotations are used more in these reports than other specialties.

APA Manual of Style

Words to avoid and recommended replacements

dictator’s preference

For APA Manual of Style, defer to this type of preference

YES

Is DSM (Diagnostic and Statistical Manual of Mental Disorders) correct to transcribe when dictated?

physicians

For Psychiatry Reports,

• FYI: Please note that ______ may reference previous editions of the DSM in dictation. Simply transcribe what was dictated.

DSM 5

what —no longer uses the Axis I-V system?

formal mental status examination

A general standard format is used for this examination components for the psychiatric setting or a physical examination.

MMSE (Mini Mental Status Examination)

Capitalize when a score is dictated (referring to the registered test).

30

What is the Max. Score for an MMSE?

23 or Below

What is the age for a cognitive impairment?

• MMSE

lowercase

If no score is dictated, write mini-mental exam in _______ letters

• (referring to a screen for cognitive impairment, not the actual MMSE).

screen

If no score is dictated, write mini-mental exam in lowercase letters (referring to a ______ for cognitive impairment, not the actual MMSE).

table format

Typically transcribe test results in psychological evaluations in this format.

templates

Typically transcribe test results in psychological evaluations in table format.

• Therefore, use _______.

Pop culture

_____ _____ often is part of the content.

reports

Use full names, dates, and locations in ______.

veterans

Maps of Europe, the Middle East, and Asia are helpful for reports for _______.

accurate

During transcription, always be ______.

GAF (Global Assessment of Functioning)

0 to 100 (100 = superior functioning in many activity types)

WHODAS 2.0

0 to 100—higher number = increasing disability.

GARF (Global Assesment of Relational Functioning)

family or other relationships (0 to 100)

SOFAS (Social and occupational functioning)

0 to 100 [superior functioning]

GDS (Global Deterioation Scale)

Dementia Scales

• 7 stages; Alzheimer disease.

FAST (Functional Assessment Staging Tool)

Dementia Scales

—7 stages; ability to perform daily activities

Involuntary Holds

• Names of the acts and statutes used in documentation.

• Transcribe as dictated—examples.

General Psychiatric Information

• Drug and alcohol use

• Family and marital harmony

• General well-being

• Job stability and satisfaction

• Purpose in life

• Self-esteem

• School performance

• Sleep pattern

• Social contacts

  • what kind of information?

Major Depression Diagnosis

Marked reduction in interest or pleasure in all activities (anhedonia) for at least 2 weeks.

2 weeks

Major Depression Diagnosis

• Depressed mood for at least ____ weeks

• Weight gain or loss

• Increased or decreased sleep

• Increased or decreased psychomotor activity

• Diminished ability to concentrate

• Recurring thoughts of death or suicide

Major depression criteria and at least 3 of the following:

Dysthymia

chronic depression that does NOT meet the major depression criteria.

Depression

Drug Treatment for ______:

• (tricyclic antidepressant)— Amoxapine, Doxepin, Norpramin, Tofranil

• Marplan, Nardil, Emsam, Parnate

• (Selective Serotonin Reuptake Inhibitor)

• TCAs; MAOIs; SSRIs

serotonin

Drug Treatment for Depression:

• Increase _____ in the brain: Paxil, Lexapro, Zoloft

Insomnia

Inadequate sleep for at least 3 nights a week for at least 1 month

• a symptom with multiple causes

15%

Insomnia

• May be as high as this percent of the general population

OTC Sleep Aids

Drugs for Insomnia

• Excedrin P.M.

• Nytol Sominex

• Extra Strength

• Tylenol P.M.

hypnotics

Drugs for Insomnia—Called _______, after the Greek word for sleep

• Estazolam (ProSom), eszopiclone (Lunesta), flurazepam (Dalmane), lorazepam (Ativan), temazepam (Restoril), triazolam (Halcion), zaleplon (Sonata), and zolpidem (Ambien)

Terminal insomnia

You wake up and cannot fall back asleep.

Bipolar disorder (manic depressive disorder)

• Mood swings between depression and mania

• Delusions, hallucinations, bizarre behavior

one

Bipolar disorder

• Manic episodes last at least ____ week

ideas

Bipolar disorder

• Flight of _____, pressured speech, reckless behavior, and/or inflated self-esteem

psychosis

Bipolar disorder

• Sometimes _______ (loss of touch with reality)

NO

For bipolar disorder, is there psychosis in major depression or anxiety disorders?

lithium salts

What is the tx for bipolar disorder?

• (antimanic agent—bipolar disease), tranquilizers, and antidepressants

Schizophrenia

Chronic or recurrent psychosis characterized by delusions and hallucinations

abulia

Flat affect with anhedonia (lack of pleasure) and ____ (inability to make decisions)

anhedonia

lack of pleasure

40

Schizophrenia is onset usually before the age of _____

physical exam

Clinical psychologist: reports do NOT always contain a _____ exam of the body systems or a list medications.

• but do list the client's ability in motor skills