The psychiatric case note.For CCR meeting27 November 2007.
Development.Medicine & Neurology: history and examination.Phenomenology detailed clinical description.Psychotherapy developmental, formulation.UK (Maudsley) manualised traditional file.Problem orientated medical notes.Computerisation and consumer input.
Traditional (Maudsley) assessment.ReferralHistory Presenting complaint.Past HistoryFamily HistoryDevelopmental HistorySocial historyMental State examination.Physical examination.FormulationDiagnosis Plan.
Referral/ Triage.Who referred?What are concerns?Is there an issue of risk?Is there an issue of urgency?Who is the proposed patient?How and when can they be seen?
History.What are the compliants?Patient.Family / whanauWider community.When, where, what is associated, exacerbating, relieving, attribution of symptoms, how long.Consequences:DisabilitySuffering.System review.
System review.CardiovascularRespiratoryGenito-urinaryNeurologicalEndocrine Psychiatric.
Psychiatric systems review.SleepEnergyAppetiteWeight gain or lossDelusions & hallucinations.Self-harm.Tedium vitae, neglect, self-harm (cutting, burning)Suicide ideation, plans, attempts.
Past history.MedicalSurgicalAllergiesCurrent medicationsSubstancesPastCurrent (Cut down Abstinent Guilt Eye opener)Forensic.
Psychiatric Past History.Previous episodes.WhenWhat were symptoms then.TreatmentMedications.Psychotherapies.Attribution recovery | continuation symptoms.CollateralOld notesFamily
Family history.MedicalPsychiatric.Relatives experiences:Service (esp. adverse)Treatment (successful and adverse).Substances.Suicide.
Developmental I: the family players.Geno-gram.Age, job.Support, conflict.Isolation or support
Developmental II: Life history.InfancyEarly childhood.Primary schoolSecondary schoolTraining / University.WorkRelationships.
Developmental III: personality.Usual (premorbid) personality.Percieved strengths & weaknesses.Hobbies, interests.Methods of coping.LossStressCurrent situation.What supports & strengths currently accessible.
Socail.Living.Who withRent or own.Food, heating.Financial Legal Current charges.Care childrenFinancial (IRD, debt, bankruptcy).Substance abuse (in twice so will ask once)
[Physical examination.]Nutrition (Height, weight. BMI)Cardiorespiratory, (pulse, BP)CirculationNeurological(abdominal and g-u very rarely, usually referred).
Mental State Examination.BOTAMIBehaviorOrientationTalk and ThoughtAffectMood Insight and Judgement.
Behaviour.Three As.AppearanceActivity.Specific comment extra-pyridoxal side-effects EPS.Comment if responding non-apparent stimuli (NAS) i.e.. Hallucinating.AttitudeRapport.
Orientation.Aware time, place, person.Level of consciousness.Bedside tests.MMSEExtensions (idiosyncratic list of tests).Clock face.Similarities and differences.Approximations.Verbal fluency.Fist-side-palm.Repeat assessment at another time if concerned organic (delirium workup first).
[Delirium workup]Rule out correctable causes.Detailed physical examination and investigations as appropriate. Usual include:CBC, CXR, MSU.LFTs [VDRL, Hep C, HIV].Na, K, Urea, CreatinineGlucoseECGCT head (any history trauma, any neurological signs).
TalkRate & FlowNormal, StaccatoLaconic. Over inclusiveMuteProsody
ThoughtFormOrganisedIncludes circumlocutory (does not lose goal)Disorganised (loss of goal)Loosening of associations word salad.NB flight of ideas manic moodContent.Describe phenomena & themes.
AffectRangeMobility.Restricted Labileaffect is weather, mood is climate.
MoodRich vocabulary mood states.AngrySadAnxiousHappyTechnical terms.Hypomanic never involves psychotic symptoms.Dysphoria implies does not currently meet criteria depression.
InsightComprehendInformation you provide & other sources.Cognitively processImpaired by defence mechanisms.CommunicateChoices to you.
[Defense mechanisms I]High adaptiveAnticipation, affiliation, altruism, humour, self-assertion, self-observation, sublimation, suppressionCompromise formationDisplacement, dissociation, intellectualisation, isolation of affect, reaction formation, repression, undoing.
[Defense mech II]Image distortion, minorDevaluation, idealising, omnipotenceDisavowalDenial, projection, rationalisation.Image distortion, majorAutistic fantasy, projective identification, splitting (self image, others)
[Defense mech III]ActionActing out, apathetic withdrawal, help-rejection complaining, passive regression.Defensive dysregulationDelusional projection, psychotic denial, psychotic distortion.
JudgementAbility to understand consequences actions.ANDAbility to take responsibility for actions.
Formulation (psychiatric)Summary sentence presentation.Predisposing factorsPrecipitating factorsPerpetuating factors.[Choice of model flows from problem]
DiagnosisDSM AxesPsychiatric syndromePersonalityMedical conditionSocial stressorsLevel of function.
Plan.Place of careRisk management (suicide, self harm, harm others)Use inpatient, respite, MHA.BiomedicalInvestigations.MedicationsECT, light therapy.PsychologicalSocialRisk management (money, child care etc).Functional assessment & rehabilitation.
Assessment Write up.Traditionally 5-6 sheets A4, or 2-4 pages typed.Plan followed opinion (driven by doctor).Risk loss previous knowledge.
Traditional note or letter.Process of interview.Content of interviewAssessmentInterventionsOngoing plan.
Psychotherapy process note.DynamicNarrative.Defences and TransferenceInterpretations.Structured.Plan / protocol session.Adherence / homeworkProcess of session.HomeworkPlan next session.
Psychopharm progress note.Process interview.Symptoms including side-effectsLevel of functionFocused mental state.Relevant investigations.Medication changes / current medications.
Current recordsBased on Problem orientated medical record Good medical record.Case management modelNegotiated with patient / client.Redundant recording: risk of contradiction.Risk Prevention PlanAdvance directiveManagement plan.Risk being unread.
[Problem orientated medical record]Invented in 1970s.Database (initial assessment & investigations.Problem list.Plan.
[Problem orientated progress notes.]List of active problems.For each problem SOAPSubjectiveObjective (MSE findings, outcome scales etc).AssessPlan