UNIVERSITY OF SAN JOSE- RECOLETOS

School of Allied Medical Sciences

Nursing Department
NCM 117 (Lecture)- Care of Clients with Maladaptive Patterns of Behavior (Acute or Chronic)
Worksheet No. 1
BRIEF MENTAL STATUS EXAMINATION

Name of Patient: __________________________________ Age: ________ Civil Status: ______________

Address: ________________________________________ Religion: _____________________________
Psychiatric Diagnosis: ___________________________________________________________________
Source of information: ☐Patient ☐Other (specify): _____________________________________

History:
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Appearance ☐Casual dress, normal grooming and hygiene

☐Other (describe):

Attitude ☐Calm and cooperative (describe)

☐Uncooperative (describe)

☐Hostile (describe)

☐Apathetic (describe)

☐Suspicious (describe)

Motor Activity ☐No unusual movements or psychomotor changes

☐Other (describe):

Speech ☐Normal rate, tone, volume, and without pressure

☐Other (describe):
 UNIVERSITY OF SAN JOSE- RECOLETOS
School of Allied Medical Sciences
Nursing Department
Mood and Affect MOOD: AFFECT:
☐Euthymic ☐Congruent
☐Irritable ☐Blunted
☐Elated ☐Flat
☐Grandiose ☐Inappropriate
☐Anxious
☐Depressed
Thought process ☐Goal- directed and logical
☐Other (describe):

Thought content ☐Delusion (specify and describe):

☐Phobia (describe):

☐Obsession (describe):

☐Magical thinking (describe):

☐Other (describe):

SUICIDAL TENDENCY HOMICIDAL TENDENCY

Ideation: ☐Yes ☐No Ideation: ☐Yes ☐No
Plan: ☐Yes ☐No Plan: ☐Yes ☐No
If yes, describe: If yes, describe:

Means: ☐Yes ☐No Means: ☐Yes ☐No

If yes, describe: If yes, describe:

Perception ☐Hallucination (Specify type and describe):

☐Illusion (describe):

☐No alterations noted

Orientation

Memory Short- term memory:

☐Intact ☐Impaired
 UNIVERSITY OF SAN JOSE- RECOLETOS
School of Allied Medical Sciences
Nursing Department
Long- term memory
☐Intact ☐Impaired

Concentration Test used:

☐Good concentration ☐Easily distracted/Inattentive

Abstract Thinking Proverb:

Patient interpretation (verbatim):

☐Abstract thinking ability is intact

☐Literal interpretation noted (Concrete thinking only)
Judgment ☐Good ☐Fair ☐Poor
Insight ☐Good ☐Fair ☐Poor
Role and Relationship Role at:
Home:

Work/School:

Relationship with:
Parents:

Siblings:

Relatives:

Neighbors:

Peer:

Summary of Significant Findings:

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 UNIVERSITY OF SAN JOSE- RECOLETOS
School of Allied Medical Sciences
Nursing Department
Formulate three (3) priority nursing diagnoses using the P-E-S format.
1.
2.
3.
Submitted by (Write names of group members):