COLLEGE OF NURSING

MENTAL STATUS EXAMINATION

PATIENT’S NAME: Alyas Rafa Ward:

Diagnosis:

Age: 21

Date of Admission: March 20, 2023

GENERAL APPEARANCE AND BEHAVIOR

The client dresses appropriately with for the occasion. There is no sign of self-care deficit
displayed in relation to the client’s personal grooming and hygiene. No bad odor can be smelled. When
asked a question, the client answers accurately. Participates with every question and the client displays
a calm behavior. No unusual movements or psychomotor movements can be observed. Throughout the
interview, the client remained attentive, engaging and the client established good eye contact and does
not wander around when conversing. The client speaks at a normal rate, the volume is enough to be
heard and the client does not seem to be pressured to answer.

AFFECT
The client is alert and oriented to person, time, place and events. The client’s expression is
appropriate to the situation. The client smiles and frowns accordingly.

MOOD
The client does not seem to be anxious, irritable, depressed or elevated. The client displays
emotions that are appropriate with the situation

THOUGHT PROCESS
The client’s thought process is linear and goal-directed. Does not change the topic. And
answers the questions without unnecessary details and does not wander or shifts from one topic to
another. There is no repetition in the client’s answers such as words or phrases.

THOUGHT CONTENT
Throughout the interview, the client has no desire to commit suicide nor the idea of self-harm.
The client knows her advantages, hobbies as well her charms. The client does not exhibit any signs of
having a delusion, hallucinations and the client does not have any phobia and compulsions.

MENTAL STATUS Date Effective Date Revised Prepared By: Approved by:
EXAMINATION
SY 2021-2022 JANUARY 2021 LOURDES OHDETTE PELAGIO DR. ALMIRA A. TENORIO, RN, MAN, MAEd
Dean
 COLLEGE OF NURSING

COGNITIVE EVALUATION
The client was attentive and oriented to person, time, place and event as she was able to state
her name, her location, date of the interview and its purpose. The client’s short term and long-term
memory were tested and it was found to be intact as she was able to repeat the given three words
successfully and, in the order, as it was asked. The client was also asked to recall a memory of how her
Christmas was celebrated. When asked to spell certain words backwards, he is also be able to count
backwards and identify objects successfully.

INSIGHT
The client is aware that she is having a difficulty in her sleep and demonstrates willingness to
explore ways to deal with the problem.

JUDGMENT
The client has a good judgment. When asked about a particular situation or how she deals with
her problem in her sleep, she explores ways in order to cope or deal with her sleeping problems

Prepared by: Limos, Lerry Claire P.

Signature over printed name

MENTAL STATUS Date Effective Date Revised Prepared By: Approved by:
EXAMINATION
SY 2021-2022 JANUARY 2021 LOURDES OHDETTE PELAGIO DR. ALMIRA A. TENORIO, RN, MAN, MAEd
Dean
 COLLEGE OF NURSING

MENTAL STATUS Date Effective Date Revised Prepared By: Approved by:
EXAMINATION
SY 2021-2022 JANUARY 2021 LOURDES OHDETTE PELAGIO DR. ALMIRA A. TENORIO, RN, MAN, MAEd
Dean
 COLLEGE OF NURSING

MENTAL STATUS Date Effective Date Revised Prepared By: Approved by:
EXAMINATION
SY 2021-2022 JANUARY 2021 LOURDES OHDETTE PELAGIO DR. ALMIRA A. TENORIO, RN, MAN, MAEd
Dean