For the inevitable moment when the medical record eats all my macros, I’m backing them up here. Also, if anyone finds them useful, feel free to steal them. I stole them from elsewhere.
Appearance: ***well-groomed, alert, co-operative Mood: ***pt states they feel depressed Affect: ***pt appears depressed, ***congruent with mood, ***stabile affect Eye Contact: ***makes normal eye contact Thought process: ***clear/organized ***tangential/flight of ideas/circumstantial Though content: ***does not appear to be attending to internal stimuli, ***denies suicidal, homicidal thoughts Insight: ***appears to have insight about own condition Judgement: ***appears to be able to anticipate consequences of their actions
Should you copy this, remember all documentation should be tailored to the particulars of your patient’s presentation and not copied from the macro. Documenting items you did not yourself elicit or that are untrue is fraudulent. This macro just serves as a guide and reminder. Cheers.