The psychiatric case note.

For CCR meeting27 November 2007.

Chris Gale

Development.

1. Medicine & Neurology: history and examination.

2. Phenomenology detailed clinical description.

3. Psychotherapy developmental, formulation.

4. UK (Maudsley) manualised traditional file.

5. Problem orientated medical notes.6. Computerisation and consumer input.

Traditional (Maudsley) assessment.

ReferralHistory Presenting complaint.Past HistoryFamily HistoryDevelopmental HistorySocial historyMental State examination.Physical examination.FormulationDiagnosis Plan.

Referral/ Triage.

1. Who referred?2. What are concerns?

1. Is there an issue of risk?2. Is there an issue of urgency?

3. Who is the proposed patient?4. How and when can they be seen?

History.

What are the compliants? Patient. Family / whanau Wider community.

When, where, what is associated, exacerbating, relieving, attribution of symptoms, how long.Consequences: Disability Suffering.

System review.

System review.

CardiovascularRespiratoryGenito-urinaryNeurologicalEndocrine Psychiatric.

Psychiatric systems review.

SleepEnergyAppetite Weight gain or loss

Delusions & hallucinations.Self-harm. Tedium vitae, neglect, self-harm (cutting,

burning) Suicide ideation, plans, attempts.

Past history.

MedicalSurgicalAllergiesCurrent medicationsSubstances Past Current (Cut down Abstinent Guilt Eye

opener)

Forensic.

Psychiatric Past History.

Previous episodes. When What were symptoms then. Treatment

Medications. Psychotherapies.

Attribution recovery | continuation symptoms.

Collateral Old notes Family

Family history.

MedicalPsychiatric. Relative’s 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. Loss Stress Current situation.

What supports & strengths currently accessible.

Socail.

Living. Who with Rent or own. Food, heating.

Financial Legal Current charges. Care children Financial (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.

“BOTAMI”BehaviorOrientationTalk 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.

Attitude Rapport.

Orientation.

Aware time, place, person.Level of consciousness.Bedside tests. MMSE Extensions (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, Creatinine Glucose ECG CT head (any history trauma, any neurological

signs).

Talk

Rate & Flow Normal, Staccato Laconic. Over inclusive Mute

Prosody

Thought

Form Organised

Includes circumlocutory (does not lose goal)

Disorganised (loss of goal) Loosening of associations word salad. NB ‘flight of ideas’ manic mood

Content. Describe phenomena & themes.

Affect

RangeMobility. Restricted Labile

“affect is weather, mood is climate”.

Mood

Rich vocabulary mood states. Angry Sad Anxious Happy…

Technical terms. Hypomanic never involves psychotic

symptoms. Dysphoria implies does not currently meet

criteria depression.

Insight

Comprehend Information you provide & other

sources.

Cognitively process Impaired by defence mechanisms.

Communicate Choices to you.

[Defense mechanisms I]

High adaptive Anticipation, affiliation, altruism,

humour, self-assertion, self-observation, sublimation, suppression

Compromise formation Displacement, dissociation,

intellectualisation, isolation of affect, reaction formation, repression, undoing.

[Defense mech II]

Image distortion, minor Devaluation, idealising, omnipotence

Disavowal Denial, projection, rationalisation.

Image distortion, major Autistic fantasy, projective

identification, splitting (self image, others)

[Defense mech III]

Action Acting out, apathetic withdrawal,

help-rejection complaining, passive regression.

Defensive dysregulation Delusional projection, psychotic

denial, psychotic distortion.

Judgement

Ability to understand consequences actions.ANDAbility to take responsibility for actions.

Formulation (psychiatric)

1. Summary sentence presentation.2. Predisposing factors3. Precipitating factors4. Perpetuating factors.[Choice of model flows from

problem]

Diagnosis

DSM Axes1. Psychiatric syndrome2. Personality3. Medical condition4. Social stressors5. Level of function.

Plan.Place of care Risk management (suicide, self harm, harm others) Use inpatient, respite, MHA.

Biomedical Investigations. Medications ECT, light therapy.

PsychologicalSocial Risk 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.

Dynamic Narrative. Defences and Transference Interpretations.

Structured. Plan / protocol session. Adherence / homework Process of session. Homework Plan next session.

Psychopharm progress note.

Process interview.Symptoms including side-effectsLevel of functionFocused mental state.Relevant investigations.Medication changes / current medications.

Current records

Based on Problem orientated medical record – Good medical record.Case management model Negotiated with patient / client. Redundant recording:

risk of contradiction. Risk Prevention Plan Advance directive Management 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 “SOAP” Subjective Objective (MSE findings, outcome

scales etc). Assess Plan

Thank you