Psychiatric Exam

System/Body Area

                                                             Elements of Examination

Constitutional

•     Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration,

5) temperature, 6) height, 7) weight  (May be measured and recorded by ancillary staff)

•     General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Head and Face

Eyes

Ears, Nose, Mouth and Throat

Neck

Respiratory

Cardiovascular

Chest (Breasts)

Gastrointestinal

(Abdomen)

Genitourinary

Lymphatic

Musculoskeletal

•     Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements

•    Examination of gait and station

Extremities

Skin

Neurological

Psychiatric

•     Description of speech including: rate; volume; articulation; coherence; and spontaneity with notation of abnormalities (eg,  perseveration, paucity of language)

•     Description of thought processes including: rate of thoughts; content of thoughts (eg, logical vs. illogical, tangential); abstract reasoning; and computation

•     Description of associations (eg, loose, tangential, circumstantial, intact)

•     Description of abnormal or psychotic thoughts including: hallucinations; delusions;  preoccupation with violence; homicidal or suicidal ideation; and obsessions

•     Description of the patient’s judgment (eg, concerning everyday activities and social situations) and insight (eg, concerning psychiatric condition)

Complete mental status examination including

•      Orientation to time, place and person

•      Recent and remote memory

•     Attention span and concentration

•      Language (eg, naming objects, repeating phrases)

•      Fund of knowledge (eg, awareness of current events, past history, vocabulary)

•     Mood and affect (eg, depression, anxiety, agitation, hypomania, lability)

Level of Exam

Perform and Document:

Problem Focused

One to five elements identified by a bullet.

Expanded Problem Focused

At least six  elements identified by a bullet.

Detailed

At least nine elements identified by a bullet.

Comprehensive

Perform all elements identified by a bullet; document every element in each shaded box and at least one element in each unshaded box.