Outline of a Mental Health Status Assessment

As found in Registered Nurses' Association of Ontario  RNAO 158 Pearl St. Toronto, Ont. M5H 1L3   Adapted from: American Psychiatric Association (1994). Diagnostic & Statistical Manual of Mental Disorders. 4th Edition. American Psychiatric Association, Washington D.C.; Trzepacz, P.T. & Baker. R.W. (1993). The Psychiatric Mental Status Examination. Oxford University Press; Robinson, D.J. (2000). The Mental Status Exam Explained. Rapid Psychler Press.    http://www.rnao.org/pda/crisis/page9.html

The following elements may be included in a mental status assessment:

• Appearance
• Motor
• Speech
• Affect
• Thought Content
• Thought Process
• Perception
• Intellect
• Insight

APPEARANCE: 

• Age: (chronological age and whether person looks this age)
• Sex, Race
• Body build (thin, obese, athletic, medium)
• Position (lying, sitting, standing, kneeling)
• Posture (rigid, slumped, slouched, comfortable, threatening)
• Eye contact (eyes closed, good contact, avoids contact, stares)
• Dress (what individual is wearing, cleanliness, condition of clothes, neatness, appropriateness of garments)
• Grooming (malodorous, unkempt, dirty, unshaven, overly meticulous, hairstyle, disheveled, makeup)
• Manner (cooperative, guarded, pleasant, suspicious, glib, angry, seductive, ingratiating, evasive, friendly, hostile)
• Attentiveness to examiner (disinterested, bored, internally preoccupied, distractible, attentive)
• Distinguishing features (scars, tattoos, bandages, bloodstains, missing teeth, tobacco- stained fingers)
• Prominent physical irregularity (missing limb, jaundice, profuse sweating, goiter,wheezing, coughing)
• Emotional facial expression (crying, calm, perplexed, stressed, tense, screaming, tremulous, furrowed brow)
• Alertness

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MOTOR: 

• Retardation (slowed movements)
• Agitation (unable to sit still, wringing hands, rocking, picking at skin or clothing, pacing, excessive movement, compulsive)
• Unusual movements (tremor, lip smacking, tongue thrust, mannerisms, grimaces, tics)
• Gait (shuffling, broad-based, limping, stumbling, hesitation)
• Catatonia (stupor, excitement)

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SPEECH: 

• Rate (slowed, long pauses before answering questions, hesitant, rapid, pressured)
• Rhythm (monotonous, stuttering)
• Volume (loud, soft, whispered)
• Amount (monosyllabic, hyper-talkative, mute)
• Articulation (clear, mumbled, slurred)
• Spontaneity

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AFFECT: 

• Stability (stable, fixed, labile)
• Range (constricted, full)
• Appropriateness (to content of speech & circumstance)
• Intensity (flat, blunted, exaggerated)
• Affect (depressed, sad, happy, euphoric, irritable, anxious, neutral, fearful, angry, pleasant)
• Mood (reported by patient/client)

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THOUGHT PROCESS: 

• Coherence (coherent, incoherent)
• Logic (logical, illogical)
• Stream (goal-directed, circumstantial, tangential {diverges suddenly from a train of thought}, loose, flight of ideas, rambling, word salad)
• Perseveration (pathological repetition of a sentence or word)
• Neologism (use of new expressions, phrases, words)
• Blocking (sudden cessation of flow of thinking & speech related to strong emotions)
• Attention (distractibility, concentration)

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THOUGHT CONTENT: 

• Suicidal or homicidal ideations
• Depressive cognition (guilt, worthlessness, hopelessness)
• Obsessions (persistent, unwanted, recurring thought)
• Ruminations
• Phobias (strong, persistent, fear of object or situation)
• Ideas of reference Paranoid ideation
• Magical ideation
• Delusions (false belief kept despite no supportive evidence)
• Overvalued ideas
• Other major themes discussed by patient/client

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PERCEPTION: 

• Hallucinations (auditory, visual, olfactory [smelling], gustatory [taste], tactile)
• Illusions (misinterpretation of actual external stimuli)
• Depersonalization
• Déjà vu, Jamais vu

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INTELLECT: 

• Global evaluation (average, above or below average)

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INSIGHT: 

• Awareness of illness

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Adapted from: American Psychiatric Association (1994). Diagnostic & Statistical Manual of Mental Disorders. 4th Edition. American Psychiatric Association,Washington D.C.; Trzepacz, P.T. & Baker. R.W. (1993). The Psychiatric Mental Status Examination. Oxford University Press; Robinson, D.J. (2000). The Mental Status Exam Explained. Rapid Psychler Press.
As found  in Registered Nurses' Association of Ontario RNAO 158 Pearl St. Toronto, Ont. M5H 1L3   http://www.rnao.org/pda/crisis/page9.html