Psychiatric Assessment Sheet
Student name
Student university id num
Psychiatric Assessment Sheet
Student name
Student university id number
Group
Hospital or complex Name
Ward
Clinical instructor Name
Date
Identifying data:
Patient name (initials letters)
Region or address
Age
Sex
Educational status
Nationality
Occupational status
Marital status
:Condition of Patient
Chief complaints for admissionfrom thepatient (subjective):
:(From his family(objective
Medical Diagnosis
Date of admitting
Duration of admission
Previous admission
Frequency & interval
Previous medication
General description:
Examples or Comments
1-Appearance:
Well groomed/not Good hygiene /bad
Grooming and hygiene
Sad/happy/others
Facial expression
Always/sometimes/rarely/no t at all
Eye contact
Within Normal/stopped/not at all
Posture
2-Motor activity:
Present/not
Tics or Mannerisms
Present/not
Stereotyping movement
Hypoactive/retardation/ hyperactive/ Agitated Excited/calm/Tremor/
catatonia //Rigidity/ within
normal
Activity
Examples or comments
3-Speech patterns:
Slow speech/rapid speech/within normal
Speed
High volume/normal/low volume
Volume
Present or not
Stuttering
other speech impairment
Examples or comments
Relationship-4
Initiation/maintenance/termination
Relation with others
Mood&affect-5
Elated /Sad /Depressed/ Irritable /Anxious/
Fearful /Guilty/Worried
/Angry/Hopeless/ withinNormal
Mood
Flat/ diminished/Appropriate Inappropriate/incongruent (sad and smiling/laughing)
Affect
Thought process:
Examples or comments
Form of the thought
Present/not
Concrete
Present/not
Abstract
Present /not
Autistic
Present/not
Realistic
Examples or comments
Stream of thought
Present/not
Flight of idea
Present/not
Neologism
Present/not
Word salad
Present/not
Echolalia
Present/not
Poverty of speech
Others
Examples or comments
Content of thought
Present/not
1-Delusion
Present/not
Delusion of persecution
Present/not
Delusion of guilt
Present/not
Delusion of grandeur
Present/not
Hypochondriacallydelusion
Others type of delusion
Present/not
2-obsession
Present/not
preoccupation-3
Present/not
4-suciadal or homicidal idea
Examples or comments
Perceptual disturbance:
Present/not
hallusination-1
Present/not
Visual
Present/not
Auditory
Present/not
Olfactory
Present/not
Gustatory
Present/not
Tactile
Present/not
2- illusion
Examples or comments
Cognitive ability
Present/not
Conscious
Time/place/person
Oriented
Remote/recent intact
Memory
Present/not
Judgment and make decision.
Present/not
Insight
Present/not
Attention and concentration
:Sleeping and Eating manner
Examples or comments
Sleeping
Yes/no
Interrupted sleep
Yes/no
Insufficient sleep
Yes/no
Difficulty in gettingoff sleep
……….hours
Duration of sleep
Eating:
]Decreased/increased
State of appetite
Quickly/slowly
Eating manner
By hand/by spoon
Drops of food
Diabetic/low salt/low fat/regular/others
Special diet consideration
Restricted food
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Medication Sheet:
Intervention nursing
Side effect
action
Route
Dose
Medication Name
Psychiatric Nursing Care Plan
:Nursing diagnoses
Related to:
Evidenced by:
Nursing Intervention
Rationale
Nursing diagnoses:
Related to:
Evidenced by:
Nursing Intervention
Rationale
