KMCH COLLEGE OF NURSING

DEPARTMENT OF MENTAL HEALTH & PSYCHIATRIC NURSING

HISTORY COLLECTION FORMAT

I. DEMOGRAPHIC DATA

 Name
 Age
 Sex
 Education
 Occupation
 Income
 Religion
 Marital status
 Address
 Name of the informant
 Ward
 Diagnosis
 IP No.
 Date of admission
 Date of care started
 Date of care ended.

II. INFORMANT HISTORY

 Relationship with the patient

 Duration of stay with the patient
 Interest to take care of the patient
 Reliability
 Adequate

III. CHIEF COMPLAINTS

1. According to Patient

2. According the Informant

According to patient

S.No. Characteristics Chief Complaints

1. Onset
2. Duration
3. Precipitating
Factors
4. Aggrevating
Factors
5. Relieving Factors

According to informant

S.No. Characteristics Chief Complaints

1. Onset
2. Duration
3. Precipitating
Factors
4. Aggrevating
Factors
5. Relieving Factors

PRESENT PSYCHIATRIC HISTORY

1. When the patient was last well.

2. Physiological and Psychological changes with reason
3. How the patient brought to the hospital
4. Present treatment
5. Any Habits
6. Negative History
V. PAST PSYCHIATRIC HISTORY
 Draw Diagram
 Onset
 Physiological & Psychological changes to as taken place
 Where they took the treatment
 Satisfied with the treament
 How they brought to the Psychiatric hospital
 What are the treatment taken
 What is the Reason for Relapse
 Any bad habits.

VI PAST MEDICAL HISTORY

VII PAST SURGICAL HISTORY
VIII FAMILY HISTORY
1. Socio Economic, Cultural and Religious background.
 Who is the breadwinner of the family.
 Monthly income
 Housing pattern
 Own
 Rent
 Facilities
 Type of family
 Nuclear
 Joint
 Relationship with the Neighbours
 Vegetarian / Non vegetarian
 Religious belief
 Religion
 Moral attitude
2. Family tree ( must include 3 generations)
3. Family History of Psychiatric Illness
 Type of Mental Illness
 Relationship with the patient
 Duration
 Treatment
 Prognosis
 Family History of Alcoholism.
 PERSONAL HISTORY :
I. Perinatal History
 PreNatal
 Natal
 PostNatal History
(i) Pre Natal History
 Check ups
 Immunization
 Exposure to any radiation
 Diet
 Medications
 Maternal Infections
 Attitude towards the Pregnancy
 Interest to carry
 Any Force
 Reason for hesitation
(ii) Natal History
 Normal delivery/ Abnormal
 LSCS
 Forceps
 Vaccum
 Full term / Any
 Cry after birth
 Meconium, urine passed
 Birth defects
(iii) Post Natal
 Post Natal complications for both Mother and Baby
II. CHILD HOOD HISTORY:
 When weaning started
 Who is the primary care giver
 Milestones development
 Behavioral &Emotional problems (Thumb sucking, temper tantrums,
stuttering,
Head banging, Body rocking, Nail biting, enuresis, Morbid fears,
Night terrers, somnambulism)
III. EDUCATIONAL HISTORY
 Age of beginning of formal Education
 Interest to go for school
 Academic performance/ Non Academic performance
 Achievements
 Relationship with teachers and peers
 Truancy
 School Phobia
 Reason for Termination
IV. PLAY HISTORY
 Type of play
 According to the age group
 Relationship with the playmates.
V. PUBERTY
 Age of secondary sexual characteristing
 Anxiety related to Puberty changes
 Age at Menarche
VI. OCCUPATIONAL HISTORY
 Age at starting work
 Jobs held in chronological order
 Appropriate to his Educational level.
 Interest to go for job
 Job satisfaction
 Reason for changing
 Relationship with
 Boss
 Coleagues
 Subaordinates
 Income
VII. OBSTETRICAL HISTORY
 Regularity of cycle
 Duration of flow
 Any Abnormalities (menorrhagia, Dysmenorrhea)
 LMP
 Termination of pregnancy if any (Reason)
 Menopause (including any associated problems)
VIII. MARITAL AND SEXUAL HISTORY
 Type of Marriage
 Arranged
 Love
 Interest
 Age of Marriage
 Satisfaction with the Marital life
 Sexual Abnormalities
 Relationship with the inlaws
X. PRE MORBID PERSONALITY
 Inter personal relationship
 Use of Leisure time
 Interest in reading, play, music, movies, creative abilities,
spent alone/with friends
 Predominant Mood
 Attitude to self and others.
 Attitude to work and Responsibility
 Religious beliefs and Moral attitudes.
 Fantasy life
 Day dreams
 Frequency and content
 Time spent
 Habits
 Eating pattern
 Elimination pattern
 Sleeping pattern
 Use of drugs, Tobacco, Alcohol
 KMCH COLLEGE OF NURSING
MENTAL STATUS EXAMINATION FORMAT (MSE)
I.GENERAL APPEARANCE AND BEHAVIOR
1. Appearance : Looking one’s age/ older/younger
2. Facial Expression : Anxious/ pleasure/ confidence/ blunted/ pleasant
3. Posture : Stooped / stiff / Guarded
4. Mannerisms : Stereotype/ Negativism / tics / Normal
5. Eye to Eye contact : Maintained / Not maintained
6. Rapport : Built Easily/ Not built / Built with difficulty
7. Dressing & Grooming : Well dressed/ appropriate / Inappropriate (to season &
situation)/ Neat & Tidy /Dirty
8. Psychomotor activity : Increased / Decreased
9. Other movements : Stereotype/ tremors/ EPS (Extra pyramidal symptoms)/
Abnormal Involuntary Movements
10. Attitude towards the
Examiner : Co-operative/ Unco-operative
II. SPEECH (One sample of speech verbatism in 2 or 3 sentences)
a. Coherence - Coherent / incoherent
b. Relevance - Relevant / irrelevant (answer to the questions appropriately)
c. Volume - Loud / Soft
d. Tone - High pitch/ Low pitch/Monotonous
e. Rate & Rhythm - Slow / Rapid
f. Reaction time - delayed/ shortened/ Immediate/ with in appropriate time.
III. MOOD
Subjective Mood
Objective Mood: (Predominant mood / Appropriate / Inappropriate/ Irritable/ labile/
Blunted)
Inference:
IV THOUGHT:
1. Stream and Form of thought: Racy thoughts/ pressure of thought/ Retarded thinking
(poverty of thought) / Thought Block/ Flight of ideas/ muddled or unclear thinking/
neologism, poverty of speech, poverty of content of speech, circumstantiality,
tangentiality, magical thinking, loosening of association, derailment, verbigeration,
perseveration, word salad and ambivalence
2. Content of thought:
Ideas / delusion of
 Grandiosity
 Reference
 Nihilistic
 Hypochondrial
 Persecutory
 Poverty (Ideas)
 Thought Insertion
 Thought control
 Thought Broadcasting
3. Possession of thought
Obscessive Phenomena
 Obscessive thoughts
 Obscessive images
 Obscessive Ruminations
 Obscessive doubts
 Obscessive impulses
 Obscessive rituals
 Phobia
 Preoccupied thought
V. PERCEPTION
a. Illusion
 b. Hallucinations – specify type & give example Auditory / Visual/ Olfactory /
Gustatory/ Tactile/ Kinesthetic
VI. COGNITIVE FUNCTIONS
1. Consciousness : Conscious/ Alert/stupors/ coma
2. Orientation
a. Time (approximately without looking at the watch, what time is it?)
b. Place (where he is now?)
c. Person (who has accompanied him or her )
Inference
3. Attention and concentration
Method of testing
 Digit forward
 Digit backward
 Serial subtractions (100-7)
Inference
4. Memory
a. Immediate - Teach an address, as after 5 mts
asking for recall
b. Recent Memory - 24 hrs recall
c. Remote memory - Asking date of birth / events occured long back
Abstract thinking
1. Proverb testing (Give a proverb and ask the inner meaning eg: Unity is strenght.
All that glitters are not gold.
2. Similarities (what is the similarities between Table and Desk)
3. Dissimilarities (What is the dissimilarities between (Potato and stone)
6. Intelligence
GK, calculation (according to the educational level)
7. Judgement
1. Personal judgement (ask questions related to future plans)
2. Social judgement (Perception of the society)
3. Test judgement (Tell one situation and ask their response to that situation)
8. Insight
Ask questions regarding
1. Where are you?
2. Why you come here ?
3. Do you have mental illness.

Mention Insight score

a. Complete denial of illness (1 mark )
b. Slight awarness of being sick (2 marks)
c. Awarness of being sick attritube it to external physical factor (3 marks)
d. Awarness of being sick, but due to something unknown in himself (4 marks)
e. Intellectual insight (5 marks)
f. True emotional insight (6 marks)

VII. Summary & Clinical Diagnosis

 KMCH COLLEGE OF NURSING
DEPARTMENT OF MENTAL HEALTH & PSYCHIATRIC NURSING
PROCESS RECORDING

Identification data
Name of the client :
Age :
Gender :
Education :
Occupation :
Religion :
Martial status :
Ward :
IP No :
Diagnosis :
Date of Admission :
Address :

General Objectives
At the end of the process recording by using 3 Domains

SPECIFIC OBJECTIVES
Participants Verbactum Inference
Nurse Both the verbal & non-verbal Write only the terminology
Client communication of both Nurse
 and the patient (write exact
answer given by the client.
Don’t use terminology)

Conclusion
Write what you have identified through this conversation (typical sighns and symptoms)
How you have
Maintained the conversation and write how you have diagnosed the client.

Signature of the student :

Time and place :

Signature of the Supervisor :

Date :