MENTAL STATUS EXAMINATION Termination Phase (MSE FORM) PATIENTS NAME: Age: A. GENERAL APPEARANCE a. Appearance: i.

Facial Expression: ii. Grooming and Dressing: iii. Body Language: 1. Posture: 2. Movement : b. Behavior: i. ( ii. ( iii. ( iv. (

) Cooperative ) Uncooperative ) Indifferent ) Others: Specify:

c. Speech: i. Quality: ( ) Talkative ( ) Scarcity ii. Rate: ( ) Fast ( ) Normal iii. Volume: ( ) Loud ( ) Weak iv. Fluency and Rhythm ( ) Slurred ( ) Hesitant

( ) Spontaneous ( ) Poverty ( ) Slow ( ) Persevere ( ) Soft ( ) Strong ( ) Clear ( ) Good Articulation

( ) Expansive

( ) Monotone

B. ASSESSMENT OF MOOD a. Mood? b. Is it appropriate for their current situation? c. Affective Expression? d. Is it appropriate to the situation? e. Is it consistent with the mood? f. Euthymic? g. Inappropriate? h. Blunted? i. Flat affect? j. Apathy k. Ambivalence? l. Depersonalization?

C. PERCEPTION AND THINKING a. Perception Disturbance i. Illusion ii. Hallucination iii. Depersonalization iv. Sexually Preoccupied b. Thought Process i. Loose Association ii. Word Salad iii. Perseveration iv. Tangeniality v. Clang Association vi. Waxy Flexibilty vii. Flight of Ideas viii. Blocking ix. Neologism x. Confabulation xi. Circumstantiality xii. Alexithymia xiii. Others: c. Thought Content i. Pre-occupation 1. Obsession Compulsion 2. Phobia ii. Thought Content Disturbance 1. Delusion of Grandeur 2. Ideas of Reference 3. Delusion of Persecution 4. Delusion of Control 5. Delusion of Religiosity

YES ( ) ( ) ( ) ( ) YES ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )

NO ( ) ( ) ( ) ( ) NO ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )

YES ( ) ( ) YES ( ) ( ) ( ) ( ) ( )

NO ( ) ( ) NO ( ) ( ) ( ) ( ) ( )

iii. Suicidal Intentions Rating Scale (SIRS) 1. ( ) 0 No evidence of past or present suicidal intention 2. ( ) 14 Shows evidence of past or present suicidal intention: a. Has not made an attempt of self destruction: In the past, made an attempt of self destruction to avoid his fear of hurting others specially his loved ones. b. Has not threatened suicide: In the past, patient had narrated that he had threatened to commit suicide out of frustration. 3. ( ) 24 Actively thinking about suicide threat 4. ( ) 34 Make a verbal suicide threat 5. ( ) 44 Actively attempted suicide or is hospitalized to prevent selfdestructive impulse. iv. Remarks/Findings:

D. SENSORIUm: Oreinted X 3 (Time, Place and Person)

E. INTELLECTUAL FUNCTIONING

F. EGO DEFENSE MECHANISM

G. LEVEL OF SELF-ESTEEM:

HIGH ( )

LOW ( )

a. Subjective Assessment: i. Things client likes about himself: ii. Things he would like to change about himself: b. Objective assessment: i. Eye Contact: ii. Personal Hygiene: iii. Participation in Group Activity CURRENT MEDICATION Drug Dose Schedule Indication Prescribed/OTC

NURSE-PATIENT INTERACTION: Nurse Verbalization Patients Verbal & NonVerbal Cues Inferences, Analysis & Techniques of communication Nurses Thoughts & Feelings

H. EVALUATION OF EXPERIENCE: I. EVALUATION OF PATIENT: J. EVALUATION OF CLINICAL INSTRUCTOR: K. EVALUATION OF AREA: