Mental Status Exam

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.

Mental Status Exam

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