The psychiatric case note.

1. The psychiatric case note. For CCR meeting 27 November 2007. Chris Gale

2. Development. • Medicine & Neurology: history and examination. • Phenomenology  detailed clinical description. • Psychotherapy  developmental, formulation. • UK (Maudsley)  manualised traditional file. • Problem orientated medical notes. • Computerisation and consumer input.

3. Traditional (Maudsley) assessment. • Referral • History Presenting complaint. • Past History • Family History • Developmental History • Social history • Mental State examination. • Physical examination. • Formulation • Diagnosis  Plan.

4. Referral/ Triage. • Who referred? • What are concerns? • Is there an issue of risk? • Is there an issue of urgency? • Who is the proposed patient? • How and when can they be seen?

5. History. • What are the compliants? • Patient. • Family / whanau • Wider community. • When, where, what is associated, exacerbating, relieving, attribution of symptoms, how long. • Consequences: • Disability • Suffering. • System review.

6. System review. • Cardiovascular • Respiratory • Genito-urinary • Neurological • Endocrine • Psychiatric.

7. Psychiatric systems review. • Sleep • Energy • Appetite • Weight gain or loss • Delusions & hallucinations. • Self-harm. • Tedium vitae, neglect, self-harm (cutting, burning) • Suicide ideation, plans, attempts.

8. Past history. • Medical • Surgical • Allergies • Current medications • Substances • Past • Current (Cut down Abstinent Guilt Eye opener) • Forensic.

9. Psychiatric Past History. • Previous episodes. • When • What were symptoms then. • Treatment • Medications. • Psychotherapies. • Attribution recovery | continuation symptoms. • Collateral • Old notes • Family

10. Family history. • Medical • Psychiatric. • Relative’s experiences: • Service (esp. adverse) • Treatment (successful and adverse). • Substances. • Suicide.

11. Developmental I: the family players. • Geno-gram. • Age, job. • Support, conflict. • Isolation or support

12. Developmental II: Life history. • Infancy • Early childhood. • Primary school • Secondary school • Training / University. • Work • Relationships.

13. Developmental III: personality. • Usual (premorbid) personality. • Percieved strengths & weaknesses. • Hobbies, interests. • Methods of coping. • Loss • Stress • Current situation. • What supports & strengths currently accessible.

14. Socail. • Living. • Who with • Rent or own. • Food, heating. • Financial • Legal • Current charges. • Care children • Financial (IRD, debt, bankruptcy). • Substance abuse • (in twice so will ask once)

15. [Physical examination.] • Nutrition (Height, weight. BMI) • Cardiorespiratory, (pulse, BP) • Circulation • Neurological • (abdominal and g-u very rarely, usually referred).

16. Mental State Examination. • “BOTAMI” • Behavior • Orientation • Talk and Thought • Affect • Mood • Insight and Judgement.

17. Behaviour. • “Three As”. • Appearance • Activity. • Specific comment extra-pyridoxal side-effects “EPS”. • Comment if responding non-apparent stimuli (“NAS”) i.e.. Hallucinating. • Attitude • Rapport.

18. Orientation. • Aware time, place, person. • Level of consciousness. • Bedside tests. • MMSE • Extensions (idiosyncratic list of tests). • Clock face. • Similarities and differences. • Approximations. • Verbal fluency. • Fist-side-palm. • Repeat assessment at another time if concerned organic (delirium workup first).

19. [Delirium workup] • Rule out correctable causes. • Detailed physical examination and investigations as appropriate. Usual include: • CBC, CXR, MSU. • LFTs [VDRL, Hep C, HIV]. • Na, K, Urea, Creatinine • Glucose • ECG • CT head (any history trauma, any neurological signs).

20. Talk • Rate & Flow • Normal, Staccato • Laconic. Over inclusive • Mute • Prosody

21. Thought • Form • Organised • Includes circumlocutory (does not lose goal) • Disorganised (loss of goal) • Loosening of associations  word salad. • NB ‘flight of ideas’  manic mood • Content. • Describe phenomena & themes.

22. Affect • Range • Mobility. • Restricted  Labile • “affect is weather, mood is climate”.

23. Mood • Rich vocabulary mood states. • Angry • Sad • Anxious • Happy… • Technical terms. • Hypomanic never involves psychotic symptoms. • Dysphoria implies does not currently meet criteria depression.

24. Insight • Comprehend • Information you provide & other sources. • Cognitively process • Impaired by defence mechanisms. • Communicate • Choices to you.

25. [Defense mechanisms I] • High adaptive • Anticipation, affiliation, altruism, humour, self-assertion, self-observation, sublimation, suppression • Compromise formation • Displacement, dissociation, intellectualisation, isolation of affect, reaction formation, repression, undoing.

26. [Defense mech II] • Image distortion, minor • Devaluation, idealising, omnipotence • Disavowal • Denial, projection, rationalisation. • Image distortion, major • Autistic fantasy, projective identification, splitting (self image, others)

27. [Defense mech III] • Action • Acting out, apathetic withdrawal, help-rejection complaining, passive regression. • Defensive dysregulation • Delusional projection, psychotic denial, psychotic distortion.

28. Judgement • Ability to understand consequences actions. AND • Ability to take responsibility for actions.

29. Formulation (psychiatric) • Summary sentence presentation. • Predisposing factors • Precipitating factors • Perpetuating factors. [Choice of model flows from problem]

30. Diagnosis DSM Axes • Psychiatric syndrome • Personality • Medical condition • Social stressors • Level of function.

31. Plan. • Place of care • Risk management (suicide, self harm, harm others) • Use inpatient, respite, MHA. • Biomedical • Investigations. • Medications • ECT, light therapy. • Psychological • Social • Risk management (money, child care etc). • Functional assessment & rehabilitation.

32. Assessment Write up. • Traditionally • 5-6 sheets A4, or 2-4 pages typed. • Plan followed opinion (driven by doctor). • Risk loss previous knowledge.

33. Traditional note or letter. • Process of interview. • Content of interview • Assessment • Interventions • Ongoing plan.

34. Psychotherapy “process” note. • Dynamic • Narrative. • Defences and Transference • Interpretations. • Structured. • Plan / protocol session. • Adherence / homework • Process of session. • Homework • Plan next session.

35. Psychopharm progress note. • Process interview. • Symptoms including side-effects • Level of function • Focused mental state. • Relevant investigations. • Medication changes / current medications.

36. Current records • Based on Problem orientated medical record – Good medical record. • Case management model • Negotiated with patient / client. • Redundant recording: • risk of contradiction. • Risk Prevention Plan • Advance directive • Management plan. • Risk being unread.

37. [Problem orientated medical record] • Invented in 1970s. • Database (initial assessment & investigations. • Problem list. • Plan.

38. [Problem orientated progress notes.] • List of active problems. • For each problem “SOAP” • Subjective • Objective (MSE findings, outcome scales etc). • Assess • Plan

39. Thank you