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It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
Serial sevens (or, more generally, the descending subtraction task; DST), where a patient counts down from one hundred by sevens, is a clinical test used to test cognition; for example, to help assess mental status after possible head injury, in suspected cases of dementia or to show sleep inertia.
The mental status examination (MSE) is an important part of the clinical assessment process in neurological and psychiatric practice. It is a structured way of observing and describing a patient's psychological functioning at a given point in time, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and ...
The informant interview is to be conducted if further information about the patient's function is required (i.e. cognitive test score 5 to 8). It consists of six questions which can be answered with “yes” (=impairment), “no” (=no impairment), “don’t know” or “N/A”. Each question is worth one point.
The mental status examination (MSE) is another core part of any psychiatric assessment. The MSE is a structured way of describing a patient 's current state of mind, under the domains of appearance, attitude, behavior, speech, mood and affect, thought process, thought content, perception, cognition (including for example orientation, memory and ...
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]
It was originally introduced by Folstein et al. in 1975, in order to differentiate organic from functional psychiatric patients [5] [6] but is very similar to, or even directly incorporates, tests which were in use previous to its publication. [7] [8] [9] This test is not a mental status examination. The standard MMSE form which is currently ...
This is the patient's description of the pain. Questions can be open ended ("Can you describe it for me?") or leading. [9] Ideally, this will elicit descriptions of the patient's pain: whether it is sharp, dull, crushing, burning, tearing, or some other feeling, along with the pattern, such as intermittent, constant, or throbbing. Region and ...