BHAARATH COLLEGE OF NURSING, CHENNAI - 73

PSYCHIATRIC HISTORY TAKING

FORMAT

Patient Identification:

 Name
 Father / husband name
 Age
 Sex
 Date of admission
 Complete postal address
 Martial status
 Religion
 Nationality
 Education
 Occupation
 Income (monthly)
 Language known
 Ward
 Diagnosis
 Source of information
 Name of the informant
 Reliability
 Adequacy
 Presenting chief complaints (chronological orders)

History of Presenting Illness:

 Duration: days/weeks/months/years
 Precipitating factors
 Effect on interpersonal relationships
 Severity
 Mode of onset: abrupt/ acute/ sub acute/ insidious
 Course: continuous/ episodic/ fluctuating/ deteriorating/ improving &
unclear
 Precipitating factors:
  Physical
 Physical illness
 Menopause
 Periods
 Child bird
 Alcohol/ drugs
 Non-compliance with medications
 Psychological
 Life events
 On-going stress
 Social
 Lack of social support
 Financial problems
PAST MEDICAL AND PSYCHIATRIC HISTORY
PSYCHIATRIC PAST HISTORY:
 Hospitalization
 Treatment taken (name, no. of session, response to therapy, etc)
 Previous episodes of the presenting complaint
 Past or ongoing psychiatric problems
MEDICAL PAST HISTORY
 Previous hospitalization
 Significant illness, both past and current
 Significant medical events such as head injury, surgery, diabetes,
hypertension, conclusions and any other major illness. This can also
include sexual abuse by a family member or close family friend.
FAMILY HISTORY
3o genogram (family of origin)
 Parents (ages, occupation, relations with service user)
 Sibtings psychiatric problems
 Family drug or alcohol abuse
 Family forensic encounters
PERSONAL HISTORY
a). Perinatal History :
 Antenatal period: (eventful/uneventful)
 Birth: premature/full term/ post mature
 Delivery : Normal / instrumental
 Birth cry : immediate / delayed
 Birth defects
 Reaction to parenthood
 Reaction of parents to the gender of child
 Post natal complications
b). Childhood History :
 Development milestone as per age
 Relationship with siblings
 Relationship of child with other family members
 Use of coping mechanisms
 Feeding : Breast fed / artificial mode of feeding
 Weaning : Age/with what/ respond to weaning
 Behaviour & emotional problems : Temper tantrum / thumb seeking /
stuttering / head banging / body rocking / nai biting / night terrors / etc
c). Educational history :
 Age of schooling
 Extra curricular activities
 Relations with teachers
 Attendance of the child in school/college
 Relations with peers
 Attitude towards schooling
 Reason for termination of studies
d). Play History :
 Participants in games / sports
 Type of play : co-operative play, solitary play
 Relation ship with play mates
 Common games played
e). Puberty :
 Age of menarche
 Age of secondary sexual characteristics
 Reaction to menarche
 Attitude to menarche
 Regularity of cycle
 Duration of flow
f). Obstetrical history :
 Last menstrual period (LMP)
 Number of children
 Any miscarriage, abortions, still births
 Adaptation to menopausal changes
g). Occupational History :
 Periods of unemployment
 Jobs started at what age
 Jobs held in chronological order
 Relationship with superiors/seniors
 Relationship with colleagues or sub ordinates
 Income at different jobs
 Status of the client on job
 Satisfaction with job
 Awards or promotion received
 Any change of job
 Attitude to work
 Reason for changing the jobs
h). Sexual & marital histor
 Family of procreation (Genogram)
 Type of marriage
 Duration of marriage
 Details of spouse and children
 Responsibilities shared between spouses
 Relationship with children
 Premarital and extra marital relationship
 Type of sexual relationship : satisfactory / unsatisfactory
  Any marital disharmony
i). Social history :
 Relationship of client with neighbors
 Hobbies
 Social activities
 Attitude of client about society
 Politics and authorities
j). Pre-morbid history :
 Moral attitude
 Living pattern : reality / fantasy
 Strength & abilities
 Social relationship
 Use of leisure times
 Religious beliefs
 Hobbies / interests
 Predominant mood ed. Anxious, pessimistic, optimistic, stable or
fluctuating, etc
 Character eg. Shy, suspicious, irritable, self – centered, impulsive,
unconfident, obsession
 Habits : food, alcohol, tobacco, drugs, sleep and elimination
 Premorbid personality
 Attitude towards work and responsiblity
 BHAARATH COLLEGE OF NURSING, CHENNAI - 73
MENTAL STATUS EXAMINATION
FORMAT
GENERAL APPEARANCE AND BEHAVIOR
 Appearance : looking one’s age / older / younger
 Level of grooming : Normal / shabbily dressed / over dressed / idio
syntrically dressed
 Level of cleanliness : adequate / inadequate / overly clean
 Level of consciousness : fully consciousness / alert / drowsy / stupors /
comatose
 Mode of entry : came willingly / persuaded / brought using force
 Facial expression : closed eyes / sad look / happy look on face
 Co cooperativeness : normal / more than so / less than so
 Eye to eye contact : maintained / difficult / not maintained
 Psychomotor activity : normal / increased / decreased
 Rapport : spontaneous / difficult / not established
 Gesturing : normal / exaggerated / odd
 Posturing : normal / catatonic posture
 Catatonic phenomenon : automatic obedience / negativism / excessive co-
operation / waxy flexibility / echo pyraxia / echolalia
SPEECH
 Initiation : spontaneous / speaks when spoken to / minimal / mute
 Reactivity time : normal / delayed / shortened / difficult to assess
 Rate : normal / slow / rapid
 Productivity : monosyllabic / elaborate replies / pressured
 Volume : normal / increased / decreased
 Tone : normal variation / monotonous
 Relevance : fully relevant / sometime off target / irrelevant
 Speak activity : usual pattern / unusual words
 Stream : normal / circumstantial / tangential
 Coherence : fully coherent / loosening of association
 Others : rhyming / punning / echolalia / perseveration / neologism
MOOD
 Subjective mood
Nurse :
Patient :
 Objective mood
Nurse :
Patient :
[Predominant mood state appropriate / inappropriate / irritable / labile /
blunted / flattened]
 Intensity of happiness : sadness / irritability / anger / worry / suspiciousness
/ fear
 Inference : appropriate/inappropriate

THOUGHT

 Stream : normal / poverty of thoughts / thought block / muddled or unclear

thought / flights of ideas / neologism
 Form : normal / formal thoughts disorders
CONTENTS
 Delusions of worthlessness / helplessness / hopelessness / guilt /
hypochondriacal / poverty / nihilistic / death / wishes / suicidal / grandiose /
reference / control / persecution / bizarre
 Thoughts alienations : thought insertion / thought withdrawal / thought
broad castings
 Obsessional / compulsive phenomenon : thoughts / images / remuneration
doubts / impulsive / rituals
 Phobias
 Guilty
 Hypochondrias
 Abstract thinking : ability to assure a mortal set voluntarily such as shifts
voluntarily from one aspects of situation to another
PERCEPTION
 Hallucinations : auditory/visual/olfactory/gustatory/tactile
Nurse:
 Patient:
 Illusions
 Inference :
COGNITIVE FUNCTION
 Level of consciousness : conscious/cloudy/comatose/delirium/stupor/coma
 Orientation: time/place/person
Nurse:
Patient:
Inference : oriented / Disoriented
ATTENTION
 Digit forward
 Digit backward
 Inference : Normally aroused /sustained with difficulty/distractibility
CONCENTRATION
 Normally sustained/sustained with difficulty/distractibility
 Serial subtraction test 100-7 / 50 -3 for five times
 Backwards name of months
 Forward name of months

MEMORY

 Immediate
 Recent : last meal , last visitors, etc
 Verbal recall – 3 unrelated objects
 5 unrelated objects, imaginary address of 5 items
 Remote:
 Personal events : like marriage date, situation during marriage or the job
 Impersonal events : such as situation related to environment

INTELLIGENCE

 General fund of information

 Scholastic performance
 Arithmetic ability : mental arithmetic / written sums
  Test for reading and writing

ABSTRACTION

 Normal or concrete
 Similarities between paired objects
 Dissimilarities between paired objects
 Proverb testing.

INSIGHT

 Degree of awareness and understanding of one’s self and the causes or

factors related to the client’s current situation or illness
 Rate or specify: full, complete, partial, limited, poor or nil
 Awareness of abnormal behaviour/experience : yes/may be/no
 Attribution to physical cause : yes/ may be/no
 Recognition of personal responsibility : yes/may be/ no
 Willingness to take treatment :

JUDGEMENT

 Rate or specify : excellent, good, impaired, poor, ill

 Personal : intact / impaired
 Social : intact / impaired
 Test : intact / impaired
 BHAARATH COLLEGE OF NURSING, CHENNAI - 73
PROCESS RECORDING
FORMAT

NAME OF THE PATIENT:

PLACE:

NAME OF THE HOSPITAL:

DOA:

DATE AND TIME:

OBJECTIVES:

NURSE / PATIENT VERBAL NON VERBAL THERAPEUTIC INFERENCE

OINTERACTION RESPONSE RESPONSE COMMUNICATION
TECHINIQUE

NURSE

PATIENT

NURSE

PATIENT

NURSE

PATIENT

SUMMARY:

CONCLUSION:
 BHAARATH COLLEGE OF NURSING, CHENNAI - 73
THE MINI-MENTAL STATE
FORMAT

Examination (MMSE)

Maximum Score

ORIENTATION
5 ( ) What is the (year) (season) (date) (month)?
5 ( ) Where are we (state) (country) (town or city) (hospital) (floor)?
REGISTRATION
3 ( ) Name 3 common objects (e.g. “apple”, “table”, “penny”).

Take 1 second to say each. Then ask the patient to repeat all 3 after
you have said them. Give 1 point for each correct answer.

Then repeat them until they lean all 3. Count trials and record.

Trials:
ATTENTION AND CALCULATION
5 ( ) Ask patient to count back by sevens, starting at 100. Alternately, spell
“world” backwards. The score is the number of numbers or words in
the correct order.

(93___86___79___72___65___)

(D____L___R____O___W____)
RECALL
3 ( ) Ask for the 3 objects repeated above. Give 1 point for each correct
answer. (Note: Recall cannot be tested if all 3 objects were not
remembered during registration.
LANGUAGE
2 ( ) Name a “pencil” and “watch”
1 ( ) Repeat the following: “No ifs, ands, or buts.”
 3 ( ) Follow a 3-stage command:

“Take a paper in your right hand,

Fold it in half, and

Put it on the floor.”

1 ( ) Read and obey the following

Close our eyes.

1 ( ) Write a sentence.
1 ( )

Copy the following design.

Total Score ________ compare this score against norms for education and age.

These numbers can be used to compare a patient's performance on the MMSE against norms for
their age and education.
Figure 8-2. Normative Data for MMSE.

Age

Education 18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 >84

4th grade 22 25 25 23 23 23 23 22 23 22 22 21 20 19

8th grade 27 27 26 26 27 26 27 26 26 26 25 25 25 23

High
29 29 29 28 28 28 28 28 28 28 27 27 25 26
School

College 29 29 29 29 29 29 29 29 29 29 28 28 27 27

These numbers can be used to compare a patient's performance on the MMSE against norms for
their age and education.

Source: Crum RM, Anthony JC, Bassett SS and Folstein MF (1993) Population-based norms for the
mini-mental state examination by age and educational level, JAMA, 18: 2386-2391.