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Category
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Examples of observation detail:
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a. General Appearance
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· Well groomed or unkempt?
· What is the person wearing?
· Are clothes appropriate for weather and situation?
· Evidence of psychomotor agitation or retardation? Give examples.
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b. Attitude and Behavior
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· Is the person cooperative, irritable, belligerent etc.?
· Is there any indication of malingering or factitious behavior? Explain.
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c. Mood and Affect
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· How does the person describe his or her mood?
· Is the person’s affect congruent with the stated mood? Explain.
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d. Content of Thought
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· Are there any delusions?
· Is the person suicidal? Homicidal? What leads you do this conclusion?
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e. Stream of Mental Activity
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· Is speech normal or tangential or circumstantial? Give Examples.
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f. Orientation
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· Is the person oriented times three?
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g. Memory
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· Remote—can person remember past events?
· Recent—can person remember 3/3 objects after 5 min?
· Immediate—how well can the person do digit span back and forward?
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h. Fund of Knowledge
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· Is the person aware of current events? Give examples.
· Does the person know the names of the president and governor?
· Can the person answer simple geography questions, such as naming bordering states?
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i. Concentration
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· Serial 7’s or 3’s? Give person’s response.
· Spell WORLD forward and backward?
· Follow a three step command?
· Difficulty following conversation. Give examples.
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j. Abstract Thinking
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· Interpret proverbs? Give examples.
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k. Insight and Judgment
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· Does the person have insight into his/her condition?
· Does the person show good judgment when asked what he/she would do if smelling smoke in crowded theater?
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