A mental status exam template is a document used to record all of your observations and results while examining a person’s mental health. A mental status exam is similar to a physical exam that involves a series of examinations and observations to reveal pathological or normal findings.
Table of Contents
- 1 The elements of a mental status exam template:
- 2 How to examine mental status?
- 3 Conclusion:
The elements of a mental status exam template:
Mental status examinations are not performed by the providers that are designed to evaluate the mental status of an individual. Most of the information related to his assessment is indirectly gathered throughout the course of a normal interview with a patient. However, this interview can give opportunity to consciously consider the components of a mental status exam template.
You may encounter persons with cognitive abilities in the course of practicing medicine daily such as;
- Significantly impaired
- Disordered thought processes
- Altered memory capacity
- Abnormal mental status
The main purpose is to classify such abnormalities as specifically as possible when they exist. Sometimes, the patient’s condition protects the comprehensive and ordered assessment of his mental status. To identify when to stop a more comprehensive examination requires some experience. In this process, forming actual diagnoses by using a mental status exam cheat sheet is the last step.
Before you can come up with a meaningful conclusion regarding the patient’s condition, you require many interactions along with information regarding the person’s normal level of function in a mental status exam cheat sheet. The elements of a mental status exam are the following;
- What is the patient’s physical appearance?
- Is the patient dressed neatly indicating clear attention to detail?
- Is the patient well dressed?
Level of alertness
- Is the patient wake, if not, then can you awake up the patient?
- Or your conversation or questions, can the patient stay focused?
- How long is the patient’s focus span?
- During talking, does the patient use a normal volume, quantity, and tone?
- Whether the patient is pleasant, agitated or cooperative?
- For the situation, is the patient’s behavior appropriate?
Orientation (Awareness of Environment)
- Do the patients know where he is and why he’s there?
- Does the patient know you?
- Can the patient tell you the day of the week and the full date?
- How’s the patient feel?
- Is the patient’s mood suitable for the situation?
- How’s the patient seem to you?
- Does the patient keep an eye contact?
- Does the patient excitable?
- Does the tone of the patient’s voice get modified as he talks?
- Is the patient talk in a logical and organized manner? If not, then how off-base is the patient?
- From your conversation, does the patient tend to stray?
- Are your patient’s thoughts perfectly linked or they scattered?
- Whether your patient paranoid or delusional?
- Whether your patient phobic or hallucinating?
- Is the patient fixate on a single idea?
- After a few minutes have passed, can the patient remember a list of objects?
- From the patient’s past, does he remember events or people?
Ability to perform calculations
- Whether the patient perform simple subtraction, addition, multiplication or division?
- For patient’s education level, are they response appropriate?
- When balancing his checkbooks or calculating change while purchasing items, has the patient noticed any difficulties?
- Does the patient provide appropriate solutions or responses while given a situation?
Higher cortical reasoning and functioning
When you give patient a situation or ask him questions, does he make abstract, concrete or bizarre interpretations? You should also check lab report templates.
How to examine mental status?
Here are some pointer that you can follow to examine the mental status of the patient;
At first, ask the patient what is his name and the name of your establishment. Then, ask what date it is.
Provide the patient a list of objects. Then, after 2 to 5 minutes, ask him to recall 3 of the objects
Ask the patient regarding his past.
For this, use a simple mathematical test. Provide the patient easy mathematical equations to solve. Also, provide him conditions where he has to calculate the amount of money he requires to pay while purchasing a number of items. Before the exam, prepare these problems and questions.
Ask the patient to name as many items as he can think of. These objects are relevant to one category such as animals, countries, and the like within a minute.
Concentration and Attention
You should ask the patient to spell a 5-letter word backward in case the patient does this effortlessly then ask him to spell a 6-letter word the same way.
Present an object to the patient. After that, ask him to name the object and its various parts.
You have to start with 1-step instructions. Increase to 2-step instructions in case the patient can follow the first one. If the patient can really follow, move on to 3-steps instructions.
Here, ask the patient to write a complete sentence. The sentence should make sense. It must have a subject and an object. There is no need to check misspelled words.
In this section, ask the patient to draw a clock. Then, provide him a certain time to mark on the clock. The patient has to draw two pentagons that intersect with each other.
Ask the patient to determine a theme between 3 to 4 objects. Indicate a couple of examples for this exercise.
You have to ask the patient a hypothetical situation that needs good judgment. For example, if a patient found a wallet in front of a police station ask him what he would do.
In conclusion, a mental status exam template is a document that allows you to record your evaluation of a patient’s current mental status. During examining mental status, observe the patient’s behavior, general appearance, any bizarre or unusual perceptions, and all other aspects of cognition.