01 Aug Select a patient that you examined during the past weeks Conduct a Comprehensive Psychiatric Evaluation?on this patient using the template provided in the Learning Resources. There
- Select a patient that you examined during the past weeks Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain. All psychiatric evaluations must be signed, and each page must be initialed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor. You must submit your document using SafeAssign. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.
- Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
00:00:15[She nervously plays with her scarf as she breathes anxiously]
00:00:25OFF CAMERA Hello Mrs. Weidre. Are you ok? Do you want some water or something?
00:00:30MRS. WEIDRE I'm ok. I'm fine.
00:00:35OFF CAMERA I understand you wanted to see me today.
00:00:40[She breathes anxiously]
00:00:40MRS. WEIDRE I just really needed to sit and talk.
00:00:40OFF CAMERA Well, tell me what's wrong, what are you feeling?
00:00:50MRS. WEIDRE I'm just so… so unsure. I'm tired of being stuck in my house. I don't like it.
00:01:00OFF CAMERA Stuck in your house? Do you have difficultly leaving your house?
00:01:05MRS. WEIDRE Yes. All the time.
00:01:05OFF CAMERA When do you go out?
00:01:10MRS. WEIDRE …maybe, once or twice.
00:01:15OFF CAMERA A day?
00:01:15[She clutches her hands to her chest]
00:01:15MRS. WEIDRE A week. Tuesdays and Saturdays.
00:01:20OFF CAMERA Why Tuesday and Saturday?
00:01:30MRS. WEIDRE Because when my husband gets home, he can go with me.
00:01:35OFF CAMERA What do you do when you go out?
00:01:40MRS. WEIDRE I take walks.
00:01:40OFF CAMERA Where do you walk?
00:01:40MRS. WEIDRE I only go to the end of the block, and then I cross the street, and turn around, and I go back around the cul-de-sac. I'll do that three times. [Losing breathe] No more, then I have to go back inside… I also go in my backyard. That's usually okay.
00:02:15OFF CAMERA On the walks, why do you have to go back after three times? What happens?
00:02:20MRS. WEIDRE [She nervously looks around] I just can't go any further.
00:02:25OFF CAMERA Is this a physical problem, knees or something?
00:02:30[She plays with her scarf]
00:02:30MRS. WEIDRE No. No. Well… maybe. I just can't breathe if I'm out any longer.
00:02:40OFF CAMERA Oh, breathing?
00:02:40MRS. WEIDRE Yeah.
00:02:40OFF CAMERA What do you feel?
00:02:45MRS. WEIDRE [Her voice quivering] I'm just so frightened. Really, really scared. You don't realize what it took for me to get here today. I really had to. I willed it. I closed my eyes and my husband turned the radio up all the way as he drove. And then he lead me into the building.
00:03:20OFF CAMERA Is there something that triggers this, anything in particular?
00:03:30MRS. WEIDRE I don't like people. Maybe that's it. I mean I can tolerate them. Ethan, the little boy next door, I'll bake things for him and say hello. Sometimes, sometimes I watch him when his parents are gone. I mean I can be around people.
Maybe that's not that's not what I meant.
00:04:00OFF CAMERA Ok, can you walk me through what happens when you do leave the house?
00:04:05MRS. WEIDRE I get shortness of breathe, everything, the world just seems to close in on me, and everything gets feels really tight, the air in my body, my chest. I get dizzy. I don't know what's wrong… I could be sick. What is this?
00:04:30OFF CAMERA There can be many different causes for this. What is it that frightens you?
00:04:40MRS. WEIDRE [She's short of breathe] Death. I'm afraid to die.
00:04:45OFF CAMERA You're afraid you might die?
00:04:50MRS. WEIDRE Yes. Among other things but that's what pops into my head.
00:04:55OFF CAMERA Is there other stuff?
00:05:05MRS. WEIDRE Cars go to fast. And there's murders and rapes that I see on the news. And flashfloods. I just think its close, its safer to stay close to home.
00:05:15OFF CAMERA How long have you had this fear?
00:05:20MRS. WEIDRE I don't really know.
00:05:20OFF CAMERA Do you know when it all started?
00:05:25MRS. WEIDRE I'm not sure.
00:05:30OFF CAMERA Do you know what started it?
00:05:30MRS. WEIDRE No.
00:05:35OFF CAMERA When was the last time you really ventured out for any length of time?
00:05:40MRS. WEIDRE Fifteen years.
00:05:45[She nervously shifts in her chair]
00:05:45OFF CAMERA That long. Is this the farthest you've been in fifteen years? What happened fifteen years ago?
00:06:00MRS. WEIDRE I don't really know.
00:06:05OFF CAMERA There is nothing that happened to you personally that could have made you afraid of dying?
00:06:10MRS. WEIDRE I always was. My mother died the year before that. But it happened little by little. First it was planes. And then I couldn't drive on the freeway, then I couldn't drive at all, then errands, then it was going out… and soon… here I am.
00:06:40OFF CAMERA It must have taken you extraordinary courage to come here today. What finally brought you to see me?
00:06:50MRS. WEIDRE My grandson was born. But I couldn't go and see him. I still haven't seen him. My daughter gave birth last week and she's not going to bring him to see me for several months and I don't want to wait that long.
00:07:10OFF CAMERA You miss out.
00:07:15MRS. WEIDRE Yes! Of course I do! My grandson is a thousand miles away and I can't leave the God damned house.
Training Title 40
Name: Ms. Connie Weidre
Age: 53 years old
Vital Signs: T- 99.0 P- 102 R 24 156/86 Ht 5’4 Wt 1lbs73
Background: Lives with her husband in Memphis, TN, has one daughter age 25. She has never worked. Raised by mother, she never knew her father. Mother with hx of generalized anxiety and was verbally abusive, abused benzodiazepines; no substance hx for patient. No previous psychiatric treatment. Has one glass red wine with dinner. Sleeps 12-13 hrs.; appetite decreased. Has overactive bladder, untreated. Allergic to Zofran; complains of headaches, takes prn Tylenol, has diarrhea 2-3 times weekly, takes OTC Imodium.
Symptom Media. (Producer). (2016). Training title 40 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-40
American Psychiatric Association. (2022). Anxiety disorders. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x05_Anxiety_Disorders
American Psychiatric Association. (2022). Obsessive compulsive and related disorders In Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x06_Obsessive_Compulsive_and_Related_Disorders
American Psychiatric Association. (2022). Trauma- and stressor-related disorders.. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x07_Trauma_and_Stressor_Related_Disorders
Sadock, B. J., Sadock, V. A., and Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.
· Chapter 9, Anxiety Disorders
· Chapter 10, Obsessive-Compulsive and Related Disorders
· Chapter 11, Trauma- and Stressor-Related Disorders
· Chapter 31.11 Trauma-Stressor Related Disorders in Children
· Chapter 31.13 Anxiety Disorders in Infancy, Childhood, and Adolescence
· Chapter 31.14 Obsessive-Compulsive Disorder in Childhood and Adolescence
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
Week 7: Comprehensive psychiatric evaluations
College of Nursing-PMHNP, Walden University
PRAC 6635: Psychopathology and Diagnostic Reasoning
Dr. Kieth Brown
TILMAN I'm terrible. Alright. I look terrible, I feel terr
Mrs. L.T., Gender: female Age: 32 years old, Race: Black
CC (chief complaint): “I have problem sleeping and has no appetite”
HPI: Mrs. L.T., a 32 year old Black lady present for evaluation due to her husband’s concern about recent changes in her behavior. Patient started to experience changes in mood and behavior after she had her first kid two months ago. She cries a lot and yells at every little thing. Patient complains about her body shape, her inability to go out and meet with friend and do other things that makes her happy. She states, “I look terrible, I feel terrible, my body is bloated, I have lines on my face, bags, I look disgusting, I want to run, but I don’t get out much, stuck at home with the kid, I haven’t seen my friends in forever, I can’t go out anymore.”
Past Psychiatric History:
· General Statement: For the first time, this patient's mental state and growth are being observed.
· Caregivers (if applicable): none
· Hospitalizations: No prior hospitalizations, detoxes, or residential therapy.
· Medication trials: there are no previous medication trial.
· Psychotherapy or Previous Psychiatric Diagnosis: No sessions of psychotherapy or psychiatric diagnoses
Substance Current Use and History: No history of Legal or illicit drug misuse
Family Psychiatric/Substance Use History: Brother was addicted to methamphetamines and took his own life through GSW. Uncle was an opioid addict, but she denied using drugs or alcohol.
Patient recently had her first child two months ago. Currently married; stay at home mother after working in community library for 5 years. Grew up with her mother after her parents divorced when she was 16; has two sisters in Troy, Alabama. Completed education through bachelor’s level, majoring in English Literature. Prior to having her baby, patient enjoys writing and could write for hours at night. No previous suicidal gestures.
· Current Medications: Trandate 100mg twice daily for treatment of hypertension, admits to missing doses due to forgetting.
· Allergies: PCN
· Reproductive Hx: Patient is married with one child but says that she currently has no sex drive.
· GENERAL: she has gained weight and feel bloated with lines on her face.
HEENT: Head: the patient denies having ever been injured in the head. Eye: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat, or difficulty swallowing.
· SKIN: Skin is not smooth, has pimples and lines that are associated with the recent childbirth.
· CARDIOVASCULAR: Refutes experiencing tachycardia or chest pains. No chest pressure or chest discomfort, no palpitation or edema.
· RESPIRATORY: Denies shortness of breath and cough.
· NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. No previous suicidal gestures, currently seems to have a distorted thinking pattern and cites suicidal thought.
· MUSCULOSKELETAL: the patient refutes experiencing joint pains
· HEMATOLOGIC: the patient says that she has never experienced anemia or hemorrhage.
· GENITOURINARY: No burning on urination, urgency, hesitancy, or odor.
Physical exam: T- 98.6 P- 88 R 18 154/92 Ht 5’1 Wt 230lbs
Diagnostic results: No diagnostic test performed.
Mental Status Examination:
Ms. F. B., a 28-year-old African American lady who looks her stated age, neatly groomed and clean. she is cooperative with examiner with no evidence of any abnormal motor activity. She was able to maintain adequate eye contact. Her speech is clear, coherent, spontaneous, appropriate with normal rate, volume, and tone. Her mood is crying/tearful, and her affect dysphoric. Her thought process is coherent, and her thought content is unremarkable. No evidence of hallucination. Cognitively, she is alert and oriented to person, place, time, situation, and time. She has no apparent deficits to attention, concentration, memory, and abstract thinking is concrete. Her insight and judgment is fair. There is risk of harm to self, and others.
An adjustment disorder is an emotional or behavioral reaction to a stressful event or change in a person's life that hinders social performance and functioning. It occurs during a period of adaptation to an important existential change or a stressful event, whether traumatic or not, and results in a depressive reaction or disturbance of emotions and behavior for a long or short time (Tonerio et al., 2019). The patient is in a postpartum period and postpartum period, in turn, involves the emotional and physical changes of pregnancy that tend to intensify and generate profound social, psychological, and physical alterations in women, which increases their risk of suffering psychiatric disorders (Tonerio et al., 2019). There is need to early and appropriate assessment of postpartum women who report emotional disturbances as Childbirth can trigger AD, which may, consequently, harm the health of mothers and newborns and affect the relationship of postpartum women with the people around them. To be diagnosed with adjustment disorder, a person must exhibit emotional or behavioral symptoms related to an identified stressor. The stressor does not have to be ongoing Multifarious, or recurring. Individuals or whole families may be affected by the stressor (Bachem, & Casey, 2018).
Major Depressive Disorder
The DSM-5 defines MDD as the presence of five or more of the specified symptoms. A diagnosis of MDD may be made if five or more of the specified symptoms are present for two weeks, according to the DSM 5. Suicidal ideation can include symptoms such as a depressed mood (signs of hopelessness or sadness), loss of enjoyment, sleep disorders (insomnia and hypersomnia), psychomotor agitation and retardation, excessive or inappropriate guilt, and recurrent thoughts of death or suicide (Cooper, 2018). Hopelessness and helplessness are the primary emotions shown by this patient.
Generalized Anxiety Disorder
According to the DSM 5, GAD is characterized by symptoms including restlessness, exhaustion, irritability, and muscular tension, as well as an inability to manage one's worrying regularly for at least six months (DeMartini, Patel, & Fancher, 2019). Research using the GAD-7 as a diagnostic tool found that symptoms including an inability to stay still or worrying about too many different things boosted a patient's rating on the scale.
The interview with the client helped reveal important information essential in the diagnosis process. It is important to be conscious of cultural prejudices and identify and clarify the patient's cultural biases. The patient should also consider mental health services' efficacy and possible obstacles to treatment objectives. People may be afraid to seek help for mental health problems because of cultural misconceptions. Expanding on the patient's upbringing, as well as their dependency on others, is essential. A better grasp of the patient's life story can help you better understand how she views family and how to better meet her unique and therapeutic objectives.
The legal and ethical considerations that I would consider while handling the patient include maintaining the patient's autonomy during the treatment process. This can be achieved by enlightening the patient about the different treatment processes that can be used in managing her case and their side effects so that she can participate in selecting the most appropriate method (Valient et al., 2019).
The health promotion exercises I recommend for the patient include adhering to the prescribed treatment regimen. This is significant because it will help eliminate the condition's clinical symptoms and increase the patient's functionality (Valiente et al., 2019).
Bachem, R., & Casey, P. (2018). Adjustment disorder: a diagnosis whose time has come. Journal of affective disorders, 227, 243-253.
Cooper, R. (2018). Diagnosing the diagnostic and statistical manual of mental disorders. Routledge.
DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of internal medicine, 170(7), ITC49-ITC64.
McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., … & Mansur, R. B. (2020). Bipolar disorders. The Lancet, 396(10265), 1841-1856.
Tenorio Ferreira, Q., Souza Vasconcelos de Lima, L., de Lima e. Silva, L. X., Ferreira Aquino,
D. M., & de Lima Castro, J. F. (2019). Adjustment disorder resulting from childbirth:
evaluation of signs and symptoms in postpartum women. Revista Eletronica de
Enfermagem, 21, 1–10. https://doi.org/10.5216/ree.v21.53876
Valiente, C., Espinosa, R., Trucharte, A., Nieto, J., & Martinez-Prado, L. (2019). The challenge of well-being and quality of life: A meta-analysis of psychological interventions in schizophrenia. Schizophrenia research, 208, 16-24.
ible. My body is bloated. I have lines on my face, bags. I look disgusting.
© 2021 Walden University Page 1 of 3
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use, social, and medical history
· Read rating descriptions to see the grading standards!
In the Objective section, provide:
· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
· Read rating descriptions to see the grading standards!
In the Assessment section, provide:
· Results of the mental status examination, presented in paragraph form.
· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case .
· Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations ( demonstrate critical thinking beyond confidentiality and consent for treatment !), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.) EXEMPLAR BEGINS HERE
CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.
HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:
N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment.
P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment.
Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. First what is bringing the patient to your evaluation. Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS. The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5-TR diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.
Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP.
General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.
Caregivers are listed if applicable.
Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?
Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)
Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both.
Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.
Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form.
Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology. However, at a minimum, please include:
Where patient was born, who raised the patient
Number of brothers/sisters (what order is the patient within siblings)
Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?
Work History: currently working/profession, disabled, unemployed, retired?
Legal history: past hx, any current issues?
Trauma history: Any childhood or adult history of trauma?
Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)
Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns
ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!
You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc.
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.
He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.
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