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MENTAL STATUS EXAM (MSE)

By Gene Bailey,2014-08-12 14:39
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MENTAL STATUS EXAM (MSE) ...

    NEW CLIENT

     BASIC MEDICAID or

     ENHANCED TRANSFER

    Specializing in Psychosocial Rehabilitation, Targeted Service Coordination, Psychotherapy, and Clinical Services since 1997.

    Word Processing / Form J1

    INTAKE ASSESSMENT

    (MED / PSYCH / SOCIAL HISTORY)

Participant’s Name: Region: IV

Date of Birth: Age:

Assessment by:

Date(s) of Assessment and Times:

Code Billed: Units:

Participant’s Current Providers are:

    1. Healthy Connections Physician/Facility:

    2. Psychiatrist:

    3. Health Care Providers:

    4. Other:

I. SERVICES REQUESTED

     Therapy PSR

     Medication Management TSC/Case Management

II. MEDICAID STATUS

     Basic Client is transferring services from:

     Enhanced Name of Agency:

III. REASONS CLIENT IS SEEKING SERVICES AT RIVERSIDE

    (Please list all)

IV. CLIENT HISTORY/MAJOR LIFE EVENTS

    (If client is new BASIC; N/A if client has a transfer CDA)

V. CLIENT’S PRESENT CIRCUMSTANCES

    A. IN THE FOLLOWING ENVIRONMENTS (in the last six months to one year)

    (Relationships, family, employment, housing, financial, social, medical, substance

    abuse)

    B. RECENT EVENTS (In the last six months to one year)

    C. CLIENT’S PRESENT RESOURCES (Financial, friends, family, services, other)

VI. CLIENT’S CURRENT SYMPTOMS

    A. What does the client say his/her diagnosis is?

    B. Who gave him/her this diagnosis?

    C. List and rate the client’s symptoms at this time using Duration / Frequency and

    Severity Rating Scale Below

    DURATION (D) Note specifics, as needed.

    1 2 3 4 5 New (less than 2 Month(s) A Year Multiple Years Long-term (life-long)

    weeks)

FREQUENCY (F) Note specifics, as needed.

    1 2 3 4 5 A few times a year Monthly Weekly At least once per Multiple times daily

    day

SEVERITY (S) Note specifics, as needed.

    1 2 3 4 5 Mildly disruptive Moderately Significant Very disruptive Severely disruptive (Get over it easily) disruptive disruption (Can’t manage it (Overwhelming,

    (Can manage it (Can only manage it 75-80% of the time) cannot function)

    most of the time) 50-60% of the time)

     D F S

     D F S

     D F S

     D F S

     D F S

VII. MENTAL STATUS EXAM

    NOTE: Record level of severity next to abnormal findings: 1=Mild, 2=Moderate, 3=Severe, X=Normal Finding

    General Observations

    Appearance Well Groomed Unkempt Disheveled Stated Age Younger Older Build Average Thin Overweight

    Average Hostile Mistrustful Withdrawn Preoccupied Eye Contact Demanding

    Activity Average Agitated Slowed

    Speech Clear Slurred Rapid Pressured Perseveration Clang Thought Content

    Delusions Grandiose Persecutory Somatic Bizarre Nihilistic

     None Reported Religious

    Other Autistic Obsessional Guarded Phobic Guilty

     None Reported Ideas of Reference Preoccupied Other:

    Self-Abuse Suicidal (assess lethality if present): Intent Plan

None Reported Self-mutilation

    Aggressive Aggressiveness (assess lethality if present): Intent Plan None Reported

    Perception

    Hallucinations Auditory Visual Olfactory Gustatory Tactile

    None Reported

    Other Illusions Depersonalization Derealization None Reported

    Thought Process

    Logical Concrete Incoherent Circumstantial Tangential Loose Racing Blocked

    Flight of Ideas

    Mood

     Euthymic Euphoric Anxious Angry Irritable Depressed

    Affect

     Full Constricted Flat Inappropriate Labile Behavior

    Cooperative Resistant Agitated Impulsive Over-Sedated Assaultive Restless Loss of Interests Anthedonia Withdrawn Dystonia Tardive Dyskinesia

    Cognition

    Impairment Orientation Memory Attention/Concentration Ability to Abstract None Reported

    Intelligence MR Borderline Average Above Average Estimate

    Insight/Judgment (if more space is needed, use reverse side)

    Elaboration of Positive Mental Findings (if more space is needed, use reverse side)

    VIII. BARRIERS TO TREATMENT/PROGRAM PARTICIPATION RATING SCALE

    Poor Fair Good Very Good Excellent

    Rate client’s self assessment and evaluator’s assessment using the above scale

     Self Assessment Transportation to get to

     Evaluator’s Assessment clinic appointments

     Self Assessment Ability to come

     Evaluator’s Assessment weekly/biweekly, etc.

     Self Assessment Ability to verbalize/be

     Evaluator’s Assessment candid about problems

     Self Assessment Ability to engage in

     Evaluator’s Assessment therapy/PSR/CM

    (motivated? hopeful?)

     Self Assessment Ability to adhere to a

     Evaluator’s Assessment treatment plan

     Self Assessment What barriers exist to

     Evaluator’s Assessment treatment?

     Self Assessment OVERALL RATING

     Evaluator’s Assessment Likelihood of success in engaging treatment at

    this time.

    Ellaboration:

IX. CLINICIAN’S DIAGNOSIS

    Axis I:

    Axis II:

    Axis III:

    Axis IV:

    Axis V/GAF: Highest past GAF:

     Diagnosis determined by: (Name of Clinician)

     Diagnosis taken from:

    (Document / Date of Document)

X. PRIORITIZE A LIST OF THE CLIENT’S GOALS FOR TREATMENT

XI. TREATMENT NEEDS/RECOMMENDATIONS

    __________________________________________________ ________________________________ Intake Assessor’s Signature and Credentials Date

    __________________________________________________ ________________________________ Intake Assessor’s Signature and Credentials Date

    __________________________________________________ ________________________________ Supervising Clinician Date

    __________________________________________________ ________________________________ Clinical Supervisor Date

XII. ADDENDUMS:

    Additional records obtained and consulted in the process of this assessment were:

     Comprehensive Diagnostic Assessment (CDA) Completed by:

    Dated:

     Other Records:

    \\Storagedrive\newstorage\Community Rehab\Forms\2008\FORM J Initial Med-Psych-Social Assessment.doc

    ? Riverside REHAB, Inc.

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