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How is mental health documented?

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Quick Answer

One way to document mental health is the mental status exam. This exam allows clinicians to record important mental functions and behaviors of their patients at a specific point in time, according to NetCE.

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In the mental status exam, clinicians appraise of the overall appearance of a patient, as well as gender, age, race and hygiene status, explains NetCE. Assessments of motor activity note whether patients are displaying psychomotor retardation or agitation, as well as their gait, ambulation and coordination abilities. Speech assessments evaluate the rate, tone, and coherence of the spontaneous speech of patients. The clinician also measures affect, including the outward expression of emotion. Finally, the evaluation of mood records patients' overall emotional presentations, such as normal, depressed, anxious or euphoric.

Clinicians also assess the thought processes of their patients and their relation to reality. The insight of patients means their ability to understand their present circumstances and mental illness, according to NetCE. Judgment refers to ability of patients to make rational decisions and the clinician may describe it as intact, impaired or poor.

Mental health providers also examine thought content, as described by their patients, according to Medscape. Important aspects of thought content include suicidal or homicidal ideation, phobias, obsessions, memory and the ability to demonstrate abstract thinking.

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