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    NCM 117 Forms

    Uploaded by

    Kasandra Dawn Moquia Beriso

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    NCM 117 Forms

    Uploaded by

    Kasandra Dawn Moquia Beriso
    14 views7 pages

    Copyright

    © © All Rights Reserved

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    DOCX, PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
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    Download as docx, pdf, or txt
    14 views7 pages

    NCM 117 Forms

    Uploaded by

    Kasandra Dawn Moquia Beriso

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    NURSING HEALTH HISTORY

    DEMOGRAPHIC PROFILE
    Name:
    Age:
    Gender:
    Date of Birth:
    Place of Birth:
    Address:
    Civil Status:
    Religion:
    Nationality:
    Educational Attainment:
    Health Care Financing:
    Attending Physician:
    Date and Time of Admission:
    Admitting Diagnosis:

    I. IDENTIFYING DATA

    II. SOURCE OF INFORMATION

    III. CHIEF COMPLAINT

    IV. HISTORY OF PRESENT ILLNESS

    V. PSYCHIATRIC HISTORY
    VI. SUBSTANCE USE/ABUSE
    ( ) Smoke
    ( ) Alcohol
    ( ) Drugs

    VII. PAST MEDICAL HISTORY

    VIII. FAMILY HISTORY

    IX. DEVELOPMENTAL AND SOCIAL HISTORY

    X. REVIEW OF SYSTEMS

    XI. MENTAL STATUS EXAMINATION

    XII. PHYSICAL EXAMINATION


    BP:
    PR:
    O2 SAT:
    RR:
    TEMP:
    HEENT:
    C/L:
    CVS:
    Abdomen:
    Back and spine:
    Extremities:

    XIII. DIAGNOSIS

    IV. TREATMENT PLAN


    MENTAL STATUS EXAMINATION
    I. APPEARANCE (Observed)
     Gait:
     Posture:
     Clothes:
     Grooming:

    II. BEHAVIOR (Observed)


     Mannerisms & Gestures:
     Psychomotor activity:
     Expression & Eye contact:
     Ability to follow commands/requests:
     Compulsions:

    III. ATTITUDE (Observed)


     Cooperative, hostile, open, secretive, evasive, suspicious, apathetic, easily distracted, focused, defensive :

    IV. LEVEL OF CONSCIOUSNESS (Observed)


     Vigilant, alert, drowsy, lethargic, stuporous, asleep, comatose, confused, fluctuating :

    V. ORIENTATION (Inquired)
     “What is your full name?”
     “Where are we at (floor, building, city, county, and state)?”
     “What is the full date today (date, month, year, day of the week, and season of the year)?”
     “How would you describe the situation we are in?”

    VI. SPEECH AND LANGUAGE (Inquired)


     Quantity - Talkative, spontaneous, expansive, paucity, poverty :

     Rate - Fast, slow, normal, pressured:

     Volume - Loud, soft, monotone, weak, strong:

     Fluency and Rhythm - Slurred, clear, with appropriately placed inflections, hesitant, with good articulation,
    aphasic:

    VII. MOOD (Inquired)


     “How are your spirits?”
     “How are you feeling?”
     “Have you been discouraged/depressed/low/blue lately?”
     “Have you been energized/elated/high/out of control lately?”
     “Have you been angry/irritable/edgy lately?”

    VIII. AFFECT (Observed)


     Appropriateness to situation, consistency with mood, congruency with thought content:
     Fluctuations - Labile, even:
     Range - Broad, restricted:
     Intensity - Blunted, flat, normal intensity:
     Quality - Sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious,
    animated, irritable:
    IX. THOUGHT PROCESS (Observed/ Inquired)
     Linear, goal-directed, circumstantial, tangential, loose associations, incoherent, evasive, racing, blocking,
    perseveration, neologisms:

    X. THOUGHT CONTENT (Observed/ Inquired)


     “What do you think about when you are sad/angry?”
     “What’s been on your mind lately?”
     “Do you find yourself ruminating about things?”
     “Are there thoughts or images that you have a really difficult time getting out of your head?”
     “Are you worried/scared/frightened about something or other?”
     “Do you have personal beliefs that are not shared by others?” (Delusions are fixed, false, unshared
    beliefs.)
     “Do you ever feel detached/removed/changed/different from others around you?”
     “Do things seem unnatural/unreal to you?”
     “What do you think about the reports in papers such as The National Enquirer?”
     “Do you think someone or some group intend to harm you in some way?”
     [In response to something the patient says] “What do you think they meant by that?”
     “Does it ever seem like people are stealing your thoughts, or perhaps inserting thoughts into your head?
    Does it ever seem like your own thoughts are broadcast out loud?”
     “Do you ever see (visual), hear (auditory), smell (olfactory), taste (gustatory), and feel (tactile) things that
    are not really there, such as voices or visions?” (Hallucinations are false perceptions)
     “Do you sometimes misinterpret real things that are around you, such as muffled noises or shadows?”
    (Illusions are misinterpreted perceptions)

    XI. SUICIDALITY AND HOMICIDALITY (Inquired)


    SUICIDALITY
     “Do you ever feel that life isn’t worth living? Or that you would just as soon be dead?”
     “Have you ever thought of doing away with yourself? If so, how?”
     “What would happen after you were dead?”
    HOMICIDALITY
     “Do you think about hurting others or getting even with people who have wronged you?”
     “Have you had desires to hurt others? If so, how?”

    XII. INSIGHT AND JUDGMENT (Observed/ Inquired)


     “What brings you here today?”
     “What seems to be the problem?”
     “What do you think is causing your problems?”
     “How do you understand your problems?”
     “How would you describe your role in this situation?”
     “Do you think that these thoughts, moods, perceptions, are abnormal?”
     “How do you plan to get help for this problem?”
     “What will you do when ____ occurs?”
     “How will you manage if ____ happens?”
     “If you found a stamped, addressed envelope on the street, what would you do with it?”
     “If you were in a movie theater and smelled smoke, what would you do?”

    XIII. ATTENTION (Observed/ Inquired)


    DIGIT SPAN (FORWARD AND REVERSE
     “I will recite a series of numbers to you, and then I will ask you to repeat them to me, first forwards and
    then backwards.” [Begin with 3 numbers – not consecutive numbers, and advance to 7-8 numbered
    sequence.]
    SPELLING BACKWARDS
     “Spell the word ‘world.’ Now spell the word ‘world’ backwards.”
    CALCULATIONS
     (Serial 7’s) “Starting with 100, subtract 7 from 100, and then keep subtracting 7 from that number as far
    as you can go.”
     (Serial 3’s) “Starting with 20, subtract 3 from 20, and then keep subtracting 3 from that number as far as
    you can go.” [Monitor for speed, accuracy, effort required, and monitor patient reactions to the request]
     “Add these numbers: (15 + 12 + 7)”
     “Multiply these numbers: (25 x 6)”
     “If something costs 78 cents and you give the cashier one dollar, how much change should you get back?”

    XIV. MEMORY (Observed/ Inquired)


    RECENT MEMORY
     “What is my name?”
     “What medications did you take today?”
     “What time was your appointment with me for today?”
    REMOTE MEMORY
     “Where were you when President Kennedy was shot?” (For patients over 40)
     “What is your Social Security number?”
     “What were the dates of your graduation from high school, college, graduate school?”
     “When and where did you get married?”
    IMMEDIATE MEMORY AND NEW LEARNING
     “I am going to ask you to remember three words (color, object, animal – e.g., blue, table, and horse) and
    I will ask you to repeat them to me in 5 minutes. Please repeat them now after me: blue, table, and
    horse.” – 5 minutes elapse – “What were those three words I asked you to remember?” [Monitor accuracy
    of response, awareness of whether responses are correct, tendency to confabulate or substitute other
    words, ability to correct themselves with category clue and multiple choice].

    XV. INTELLECTUAL FUNCTIONING (Observed/ Inquired)


    INFORMATION AND VOCABULARY
     “Name the last 5 presidents.”
     “Name 5 of the largest cities in the country.”
     “Name the current president, vice president, governor, and mayor.”
    VOCABULARY
     Grade school level, high school level, fluent, consistent with education:
    ABSTRACTION
     Similarities – “How are the following items similar?”
     “An apple and an orange” (round ~concrete, fruit ~abstract)
     “A chair and a table” (made of wood ~concrete, furniture ~abstract)
     “A watch and a ruler” (measurement instruments ~abstract)
     Proverbs – “How would you describe the meaning of the following sayings?”
     “People living in glass houses should not throw stones.”
     “A bird in the hand is worth two in the bush.”
     “You shouldn’t cry over spilt milk.”
     “Two heads are better than one.”
    PROCESS RECORDING
    HEALTH CARE PROVIDER CLIENT FINAL COMMENT
    ANALYSIS ANALYSIS
    VERBAL NON-VERBAL VERBAL NON-VERBAL OR FEEDBACK

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