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| Individual mental state assessment
- Appearance
- Simply describe the patient's physical presentation: clothing,
hygiene and cultural appropriateness.
- Behaviour
-
Briefly describe the patient's behavioural style, including
agitation, retardation, and any inappropriate or unusual
behaviour.
- Conversation
-
Describe both the content of conversation, perhaps with some quotes,
as well as the form, which includes the rate of conversation, as well as
the logic, or otherwise, of thought processes.
- Affect and mood
-
Note the individual's mood level, variability, range, intensity and
appropriateness.
- Perceptual abnormalities
-
Note any psychotic symptoms, or other perceptual abnormalities,
including hallucinations and delusions. These perceptual
abnormalities can occur in any of the five senses.
- Cognition
-
Describe orientation, memory and attention, or ability to
concentrate. The Mini Mental State Examination is an excellent brief cognitive
assessment that can be performed by most clinicians in three to five
minutes.
- Dangerousness
-
Comment on any suicidal or homicidal ideas, beliefs or feelings.
- Insight
-
Assess the patient's insight into his or her condition. This may be
hard to judge, but is particularly important because of the
management implications of poor treatment compliance.
- Judgement
-
Assess the patient's level of judgement, in particular regarding
safety issues.
- Rapport
-
Briefly comment on how you believe the interaction was between
yourself and the patient, and in particular how the patient made you
feel.
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