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History
Mode of referral / Presenting complaint
Provide a sentence or two explaining how the patient came to access services on this occasion.
Include admission status. Top
History of present condition
Fairly full account of development of current episode of illness in chronological order. If
there are things which will be described later in detail under Mental State Examination then
only brief summary need be given here, e.g. "worsening depression
with biological features", "many persecutory and grandiose
delusions".
It is important that this section provides an account of the time course of the presenting problem(s). If necessary bring together information obtained from a variety of sources and reorganised into chronological order. (If there are any physical symptoms that are volunteered or discovered on systematic enquiry, an account of these should also be given here.) Also document here all attempts at treatment of the current disorder, including effectiveness and side effects. Be sure to include any psychological treatments. Also document here interventions which form part of the Care Program Approach, such as support from a Community Mental Health Nurse and day centre attendance. Top
Drug history
Medication the patient is taking or should be taking, with rough duration. Top
Past psychiatric history
Include timing, rough length and whereabouts of past admissions. Find
out past treatments and response to them, in particular ECT, lithium,
depot neuroleptics. Make sure to get history of any self-harm and record
it even as a negative, and of violence to others. Find out about
previous out-patient or general practice treatment. It is very easy to
miss past and present counselling/psychotherapy (many people presenting
in a crisis seem to deliberately omit mention of this) so ask about it
specifically. Top
Past medical history
Significant illnesses, operations. Top
Family history
Parents' occupations, age now/at death. (Be aware of age of patient when bereaved.) Approximate quality of relationship with each other and patient. Any other notable features, e.g. serious illness. Numbers and ages of siblings with brief account of their social adjustment, relationship with patient. Presence and nature of any known psychiatric illness or alcohol abuse in any first or second degree relatives. Top
Personal history
Life history from birth until present, including geographical information. Birth, childhood. (Include milestones and "neurotic traits" if you want to.) How got on at schools: socially, academically, athletically. Age finished education and qualifications obtained. Occupational history - some account of number/nature/duration of jobs, maybe reasons for leaving, etc. Psychosexual history - orientation, first SI, number/length of longest/most recent relationship, etc. Enquire about childhood sexual abuse. Number of children, with sex, age and parentage of each. Top
Forensic history
Convictions, sentences. Also include here any history of violent behaviour which may not have resulted in a criminal conviction. Top
Social history
Where living and with whom, income, social support. Contact with children. Alcohol, tobacco, other recreational drugs.Top
Premorbid personality
Or if chronic illness then best functioning when not acutely unwell. Interests, recreations, activities. Degree of sociability. Obsessional/anxious/depressive traits. Top
Mental state examination
Appearance
Cleanliness, grooming, dress, size, apparent age, etc. Obvious physical signs such as tremor, goitre, ptosis. Top
Behaviour
Rapport. Degree of cooperation. Motility, gestures, disinhibition.Top
Speech
Rate, volume, quantity, fluency. Any accent, dysarthria, problems with language. Use of obscenities. Mention briefly gross thought disorder, neologisms, obvious dysphasia. Uninterruptible? Top
Mood
Subjective mood over last days/weeks. Variability of mood. Energy, enjoyment, interest, anhedonia? Reports being tearful? Recent and current suicidal intent. Biological features of affective disorder: appetite, weight, sleep (initial/middle/terminal insomnia), diurnal mood variation, libido, constipation.
Top
Affect
Impression of mood conveyed to observer ("objectively") by facial expressions, etc. Ever smiles, cries? Appropriateness, lability.Top
Thought form
(Abnormalities of stream usually included here.) Loosening of associations, derailment, neologisms, punning, clang associations, etc. Appropriateness of answers. Subjective rate, quantity, experience of thought block. Poverty of content?Top
Thought content
Include passivity experiences and thought insertion, broadcasting, withdrawal.
Delusions, over-valued ideas.
Depressive cognitions consisting of low self-esteem, guilt, hopelessness.
Grandiosity.
Preoccupations, obsessions.
Traditionally compulsive behaviours, panic attacks and anxiety-related symptoms are often described here.Top
Perceptions
Hallucinations, illusions. Describe modality and nature, taking particular care in relation to possible first-rank symptoms. Put depersonalisation here.Top
Cognition
If nothing else, apparent level of consciousness. Orientation. Concentration, attention (digit span, serial sevens). Short term memory (name and address, recent events). Further testing when indicated for: naming/comprehension difficulties, constructional apraxia, dysgraphia, left-right orientation, verbal fluency, sensory/visual inattention, perseveration, astereognosis. May include subjective estimate of approximate intelligence. Top
Insight
Patient's view of diagnosis and aetiology. Extent of compliance with treatment plans.Top
Physical examination
Findings on admission. Top
Investigations
Investigations performed and results. Top
Treatment and progress
Account of response to treatment interventions contained in a few sentences describing course of admission. Other developments during the course of admission should also be documented here. Top
Final diagnosis
All applicable diagnoses with ICD10 codes, including for concomitant physical disorders. Top
Medication on discharge
List all medications, including for physical conditions, along with doses. Top
Follow-up arrangements
Identities and roles of professionals who will be involved with aftercare, CPA status and name of care coordinator. Top
Prognosis
A sentence or two about the likely future course, often with a note about the dependence of the prognosis on the patient's compliance with treatment. Top
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Dave Curtis (http://www.davecurtis.net/dcurtis.html)
Copyright Dave Curtis 1995-2011. You can distribute this material freely provided my copyright remains acknowledged. Top