Rewatch the same Patient Interview. You will now write the mental status exam portion of the psychiatric report
Rewatch the same Patient Interview. You will now write the mental status exam portion of the psychiatric report
Rewatch the same Patient Interview. You will now write the mental status exam portion of the psychiatric report. The mental status exam can be written in bulleted or narrative format, but should include the following sections:
- Appearance – personal identification, behavior, psychomotor activity, general description
- Speech
- Mood and affect
- Thinking and perception – form of thinking, content of thinking, thought disturbances, perceptual disturbances
- Sensorium – alertness, orientation, memory, concentration, fund of knowledge, abstract thinking
- Insight
- Judgement
An example is outlined on page 24 of Kaplan & Sadock’s Synopsis of Psychiatry textbook.
Rubric
Psychiatric Report: Mental Status Exam
| Psychiatric Report: Mental Status Exam | ||
| Criteria | Ratings | Pts |
| This criterion is linked to a Learning OutcomeMental Status Examination | 50 pts Proficient Provides at least 10 details in the mental status examination that clearly relate to the patient presented in the scenario. 37.5 pts Acceptable Provides at least 8 details in the mental status examination that are mostly relevant to the patient presented in the scenario. 25 pts Needs Improvement Provides at least 6 details in the mental status examination. Some information is vague, may not be correct, or may not relate to the patient presented in the scenario. 12.5 pts Unsatisfactory Provides 4 details in the history of the present illness. The information is vague, incorrect, or does not relate to the patient presented in the scenario. 0 pts Missing Does not provide a mental status examination. | 50 pts |
| This criterion is linked to a Learning OutcomeStrengths and Limitations | 20 pts Proficient Provides at least 4 details in the strengths and limitations that clearly relate to the patient presented in the scenario. 15 pts Acceptable Provides at least 3 details in the strengths and limitations that are mostly relevant to the patient presented in the scenario. 10 pts Needs Improvement Provides at least 2 details in the strengths and limitations. Some information is vague, may not be correct, or may not relate to the patient presented in the scenario. 5 pts Unsatisfactory Provides one detail in the strengths and limitations. The information is vague, incorrect, or does not relate to the patient presented in the scenario. 0 pts Missing Does not discuss strengths and limitations. | 20 pts |
| This criterion is linked to a Learning OutcomeOrganization | 15 pts Proficient All data and information is placed in the correct section of the note. The note is well organized and clear. 11.25 pts Acceptable Minor mistakes in placement of information and data. The note is mostly organized and clear. 7.5 pts Needs Improvement Several mistakes in placement of information and data that impact the organization and clarity of the note. 3.75 pts Unsatisfactory Numerous mistakes in placement of information. The note is not well organized and is difficult to understand. 0 pts Missing Information unreadable, multiple mistakes in organization of data, information is unclear. | 15 pts |
| This criterion is linked to a Learning OutcomeTerminology | 15 pts Proficient Appropriate use of medical terminology. No grammar/ spelling mistakes. 11.25 pts Acceptable Minor mistakes with terminology, spelling or grammar. 7.5 pts Needs Improvement Several mistakes with terminology, spelling or grammar. 3.75 pts Unsatisfactory Frequent mistakes with terminology, spelling or grammar that impact the reader’s ability to understand the note. 0 pts Missing Information is unreadable, multiple mistakes, and the information is unclear. | 15 pts |
| Total Points: 100 | ||
Requirements: 2 pages | .doc file
Nursing
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