Psych Ie
Psych Ie
Psych Ie
(2/21/23)
SUBJECTIVE:
Informant:_________________
I. Chief Complaint (C/C)
⮚ Presenting complaint (verbatim/ informant)
⮚ Pt’s. own words or informant/s’ why he or she has come or been brought in for help.
II. Premorbid Personality
⮚ (before Sx appeared)
⮚ Caretaker/ chart/ not determined if none
III. HPI (paragraph form)
⮚ Through caretaker, Pt. (interview), chart
⮚ Onset and precipitation factors
⮚ cause/reasons of admission
⮚ provides a comprehensive and chronological picture of the events leading up to the current
moment in the patient's life
IV. Family History
⮚ brief statement about any psychiatric illness, hospitalization, and treatment of the patient's
immediate family members
⮚ provide a description of the personalities and intelligence of the various persons living in the
patient's home from childhood to the present as well as a description of the various
households in which the patient lived ⮚ state if single, married, divorced
A. Single/ Married
1. If single:
a. # of siblings
b. Rank of Pt
c. Parents (living/ deceased, & occupation)
d. Closest sibling
e. Closest parent
f. Best friend/s
2. If married:
a. # of children
b. Age range of children (eldest: ___ youngest: ___)
c. # of married children
d. # of working children
e. Child closest to
f. Name of spouse
B. Relationship with parents/ siblings/ spouses/ children (paragraph form)
⮚ Pt’s. attitudes toward his sibling and family members
⮚ Pt’s. description of the parents’ occupation
⮚ What does each sibling do in comparison to what the Pt. is doing?
V. PERSONAL HISTORY (ANAMNESIS)
A. Prenatal and Perinatal Hx (paragraph form)
⮚ Events before and during birth of the Pt.
⮚ Was the Pt. wanted/ planned
⮚ Problems during pregnancy and delivery
⮚ Did mother use alcohol or any substances
B. Early Childhood (0-3 years) (paragraph form)
⮚ Parent-child interactions
⮚ Play hx
⮚ Feeding habits, early devt., toilet training
⮚ Beh. Problems, personality as a child
⮚ Dreams/ fantasies
C. Middle Childhood (3-11 yrs.) (paragraph form)
⮚ Relationships at school, home, and at play
D. Late Childhood (Puberty to Adolescence) (paragraph form)
⮚ Social relationships
⮚ School hx, cognitive and motor devt.
⮚ Emotional and physical problems
⮚ Sexuality issues
E. Adulthood (paragraph form for each subarea)
a. Educational Background
⮚ Highest education attained
⮚ Attainment of siblings in relation to the Pt’s
⮚ Pt’s attitude towards academic achievement
b.Work History
⮚ Occupation prior to d/a or present occupation
⮚ Duties/ responsibilities in present job
⮚ Other work experience
⮚ Present means of support
c. Hobbies/ Interest and Social Activities
d.Marital and Relationship Hx
e. Religion
f. Current Living Situation
⮚ Neighborhood and residence
⮚ Sources of family income and financial hardships
⮚ Home situation
g. Legal Hx
⮚ Arrests, or any acts of violence
h.Psychosexual Hx
⮚ Any sexual problems and relationships
OBJECTIVE:
(indicate grade before every item)
Mental Status Exam
⮚ part of the clinical assessment that describes the sum total of the examiner's observations and
impressions of the psychiatric patient at the time of the interview
⮚ description of the patient's appearance, speech, actions, and thoughts during the interview
3. Schneiderian Symptoms
Tester’s Question Patient’s Response
Loosening of Associations (schiz) Ideas shift from one subject “What is your name?” Response
to another that is “ A rose by any other name….I
completely wish I could get out of
unrelated. The speaker does not here…Jigsaw puzzles are fun.”
show any awareness that the
topics are unconnected
Circumstantiality and Tangentiality The person disgresses, giving “When were you in the
unnecessary, irrelevant hospital?” Circumstantial
information. When speech is response: “I went to this great
circumstancial, there is difficulty concert last summer after I
getting to the point of the visited my aunt.” Tangential
conversation, yet in the person’s response: In the fall….the leaves
mind, the answers are related. In were so beautiful…They were
tangential speech, the person like paintings. My art is my soul.”
starts answering a question but
then rapidly digresses.
Neologism An invented word that may “Why were you admitted to the
closely resemble an existing hospital?” Response: “ It come
word or may be known only to from too much normiation, a sort
the individual. of infestation of some sort. I was
being institized.”
Name this hospital or building. Unsay ngalan sa aning lugara nga naa 1
ka karon?
What is the date today? Unsa man ang petsa karong adlawa? 1
What country are you in? Unsa nga nasod nga naa ka karon? 1
What province are you in? Unsa nga probinsiya nga naa ka karon? 1
What floor of the building are Unsa nga floor (1/2/3) nga naa ka karon? 1
you in?
What day of the week is it? Unsang adlawa karon karong semanaha? 1
2b. Registration
2d. Recall
2e. Language
TOTAL 30
F. Judgement
i. Intellectual
Tester’s Questions
a. Kung maka punit ka ug pitaka nga naai ID ug kwarta sa sulod, unsa imong buhaton?
b. Kung mag linog, unsa imong buhaton?
c. Kung masaag ka sa usa ka lugar, unsa imong buhaton?
Patient’s Responses
1.
2.
3.
ii. Social
Tester’s Questions
a. Unsa imong opiniyon or pananaw sa corruption?
b. Unsa imong opiniyon or pananaw sa poverty?
c. Unsa imong opiniyon or pananaw sa abortion?
Patient’s Answers
1.
2.
3.
LEGEND:
Good – able to answer 3 questions correctly and properly
Fair – able to answer 2 of 3 questions correctly and properly
Poor – able to answer 0/1 of 3 questions correctly and properly
G. Abstract Thinking
TV Radio
Chair Table
Pencil Ballpen
Legend:
Poor = cannot detect differences/ similarities
Fair = differences/ similarities are concrete
Good = more of fxn, sim/diff are visible or seen
LEGEND:
Good – able to answer 3 questions appropriately
Fair – able to answer 2 of 3 questions appropriately
Poor – able to answer 0/1 of 3 questions appropriately
2. Self-confidence
LEGEND:
Good – able to carry out talents and abilities without hesitations
Fair – hesitant n executing one’s abilities and needs furthermore encouragement
Poor – unable to carry out one’s abilities
J. Insight - the patient's degree of awareness and understanding about being ill
o Levels of insight
1. Complete denial of illness
2. Slight awareness of being sick and needing help, but denying it at the same time
3. Awareness of being sick but blaming it on others, on external factors, or on organic factors
4. Awareness that illness is caused by something unknown in the patient
5. Intellectual insight: admission that the patient is ill and that symptoms or failures in social adjustment are caused by
the patient's own particular irrational feelings or disturbances without applying this knowledge to future experiences 6.
True emotional insight: emotional awareness of the motives and feelings within the patient and the important persons
in his or her life, which can lead to basic changes in behavior.
WORK BEHAVIOR
A. Attitude towards work/act./interview
⮚ Motivation,
⮚ approach to act.
LEGEND:
Good - no prodding, active participation
Fair - passive to active participation, (+) mod. prodding
Poor - Pt. doesn’t participate, passive participant, needs maximal prodding
B. Work Ability
1. Follows instruction
LEGEND:
Good – able to follow instruction effectively
Fair – able to follow instructions but has to repeat he procedures several times
Poor – difficulty following instructions and needs to be refreshed and guided throughout the activity
3. Supervision needed
LEGEND:
No supervision needed – can complete an activity even without the presence of therapist
Minimal Supervision – can do 75% of the activity; needs 25% of therapist’ support to complete the activity
Moderate Supervision – can do 50% of the activity; needs 50% of therapist’ support to complete the activity
Maximal Supervision - can do only 25% of the activity; but still needs therapist’ full support to complete the
activity
4. Attention span
LEGEND:
Good – attends to activity within ≥ 30 minutes
Fair – attends to activity within 15 to 29 minutes
Poor – attends to activity less than 15 minutes
5. Concentration
LEGEND:
Good – able to accomplish activity without being distracted (no problems noticed in working
environment, with others doing loud tasks)
Fair – able to accomplish activity but easily distracted, however able to return to activity
given when prompted (in working environment, with others doing quite task)
Poor – easily distracted, unable to accomplish task given (worked only when
environmental distractions were at a minimum, outside the group)
6. Skill (quality of project) (when applicable)
LEGEND:
Good – has appropriate skill in performing the task and uses materials properly without cueing or assistance
Fair – has appropriate skill in performing the task and uses materials properly w/
moderate cueing or assistance Poor – has inappropriate skill in performing a task and
improper use of materials
7. Frustration Tolerance
LEGEND:
Good – able to finish activity without signs of frustration, irritability or giving up with more difficult
task Fair – able to finish activity but needed to be prompted by therapist in order not to give up
Poor – unable to finish activity or easily frustrated with simple task
8. Impulse Control
LEGEND
Good – thinks before acting and waits for signals
Fair – thinks before acting but can’t wait for signals
Poor – acts out immediately on impulse
9. Problem solving
LEGEND
Good - Able to recognize problems and find realistic solutions independently
Fair – Able to recognize problems but cannot foresee solutions
Poor - Unable to recognize problems or suggest solutions
10. Decision-making
LEGEND
Good – able to make decisions effectively without relying on others
Fair – able to make decisions but relies on other opinion and feedback
Poor – always relies on others on making decisions
ASSESSMENT:
∙ Stating your hypothesized prognosis in performance areas based from your findings noted during the
interview, clinical evaluation, and medical prognosis (according to literature).
- Pt has (good/ guarded/ poor) prognosis in (area) (performance, skills, and contexts)
∙ Determining your OT problem list by assessing which activity demands, contexts, performance skill
deficits, missing performance components or client factors are limiting occupational performance
OT PROBLEM LIST
1. Pt has difficulty in (Performance Area) secondary to (which activity demands, contexts, performance skills
deficits, missing performance components or client factors are limiting occupational performance)
associated with / secondary to (MEDICAL DIAGNOSIS)
2.
PLAN
TREATMENT PLANNING
1. Problem
Long Term Goal
∙ The acceptable form: To improve (AREA):
RECOMMENDATIONS: