UNIVERSITY OF THE BAHAMAS
SCHOOL OF NURSING AND ALLIED HEALTH PROFESSIONS
DEPARTMENT OF NURSING
NURS 306: Psychiatric/Mental Health Nursing
Mental Status Examination Documentation Sheet
Student Name:
ID#:
DEMOGRAPHIC INFORMATION
Client’s Initials:
Age:
Gender:
DOB:
Ethnicity:
DOA:
Marital Status:
Religion:
Occupation:
Allergies:
Educational Level:
Socio-economic Level:
Address:
Current Psychiatric Diagnosis:
Co-existing Diagnosis/Diagnoses:
PATIENTS HISTORY
Chief Complaint
History of Psychiatric Illness
Past Illnesses
Family History
Social History
Drug/Forensic History
Personal History
REVIEW OF PSYCHOLOGICAL SYSTEM
Cognitive Abilities
Response To Illness
Response To Care
Cultural Implications
Developmental Data
1
UNIVERSITY OF THE BAHAMAS
SCHOOL OF NURSING AND ALLIED HEALTH PROFESSIONS
DEPARTMENT OF NURSING
NURS 306: Psychiatric/Mental Health Nursing
Mental Status Examination Documentation Sheet
Student Name:
ID#:
MENTAL STATUS EXAMINATION
General Appearance
Motoric Behaviour
Attitude
Mood
Affect
Speech & Language
Thought Processes
Thought Content
Perceptions
Judgment & Insight
Orientation
Attention & Concentration
Memory (remote, recent &
immediate)
Abstract Thinking
PSYCHOLOGICAL FORMULATION
Predisposing Factors
Precipitating Factors
Perpetuating Factors
Protective Factors
Interpretation & Analysis
Strengths & Weaknesses
2
UNIVERSITY OF THE BAHAMAS
SCHOOL OF NURSING AND ALLIED HEALTH PROFESSIONS
DEPARTMENT OF NURSING
NURS 306: Psychiatric/Mental Health Nursing
Mental Status Examination Documentation Sheet
Student Name:
ID#:
NURSING MANAGEMENT
Maslow Category
NANDA NEED
3
UNIVERSITY OF THE BAHAMAS
SCHOOL OF NURSING AND ALLIED HEALTH PROFESSIONS
DEPARTMENT OF NURSING
NURS 306: Psychiatric/Mental Health Nursing
Mental Status Examination Documentation Sheet
Student Name:
ID#:
PRIORITY NEED #1
ASSESSMENT
Subjective Data
Objective Data
NURSING DIAGNOSIS
OUTCOME IDENTIFICATION
Short Term
Long Term
INTERVENTIONS
RATIONALES
IMPLEMENTATION
EVALUATION
4
UNIVERSITY OF THE BAHAMAS
SCHOOL OF NURSING AND ALLIED HEALTH PROFESSIONS
DEPARTMENT OF NURSING
NURS 306: Psychiatric/Mental Health Nursing
Mental Status Examination Documentation Sheet
Student Name:
ID#:
PRIORITY NEED #2
ASSESSMENT
Subjective Data
Objective Data
NURSING DIAGNOSIS
OUTCOME IDENTIFICATION
Short Term
Long Term
INTERVENTIONS
RATIONALES
IMPLEMENTATION
EVALUATION
5
UNIVERSITY OF THE BAHAMAS
SCHOOL OF NURSING AND ALLIED HEALTH PROFESSIONS
DEPARTMENT OF NURSING
NURS 306: Psychiatric/Mental Health Nursing
Mental Status Examination Documentation Sheet
Student Name:
ID#:
PRIORITY NEED #3
ASSESSMENT
Subjective Data
Objective Data
NURSING DIAGNOSIS
OUTCOME IDENTIFICATION
Short Term
Long Term
INTERVENTIONS
RATIONALES
IMPLEMENTATION
EVALUATION
6