Top Banner
The psychiatric case note. For CCR meeting 27 November 2007. Chris Gale
39

The psychiatric case note.

Jan 06, 2016

Download

Documents

vanya

The psychiatric case note. For CCR meeting 27 November 2007. Chris Gale. Development. Medicine & Neurology: history and examination. Phenomenology  detailed clinical description. Psychotherapy  developmental, formulation. UK (Maudsley)  manualised traditional file. - PowerPoint PPT Presentation
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Page 1: The psychiatric case note.

The psychiatric case note.

For CCR meeting27 November 2007.

Chris Gale

Page 2: The psychiatric case note.

Development.

1. Medicine & Neurology: history and examination.

2. Phenomenology detailed clinical description.

3. Psychotherapy developmental, formulation.

4. UK (Maudsley) manualised traditional file.

5. Problem orientated medical notes.6. Computerisation and consumer input.

Page 3: The psychiatric case note.

Traditional (Maudsley) assessment.

ReferralHistory Presenting complaint.Past HistoryFamily HistoryDevelopmental HistorySocial historyMental State examination.Physical examination.FormulationDiagnosis Plan.

Page 4: The psychiatric case note.

Referral/ Triage.

1. Who referred?2. What are concerns?

1. Is there an issue of risk?2. Is there an issue of urgency?

3. Who is the proposed patient?4. How and when can they be seen?

Page 5: The psychiatric case note.

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.

Page 6: The psychiatric case note.

System review.

CardiovascularRespiratoryGenito-urinaryNeurologicalEndocrine Psychiatric.

Page 7: The psychiatric case note.

Psychiatric systems review.

SleepEnergyAppetite Weight gain or loss

Delusions & hallucinations.Self-harm. Tedium vitae, neglect, self-harm (cutting,

burning) Suicide ideation, plans, attempts.

Page 8: The psychiatric case note.

Past history.

MedicalSurgicalAllergiesCurrent medicationsSubstances Past Current (Cut down Abstinent Guilt Eye

opener)

Forensic.

Page 9: The psychiatric case note.

Psychiatric Past History.

Previous episodes. When What were symptoms then. Treatment

Medications. Psychotherapies.

Attribution recovery | continuation symptoms.

Collateral Old notes Family

Page 10: The psychiatric case note.

Family history.

MedicalPsychiatric. Relative’s experiences:

Service (esp. adverse) Treatment (successful and adverse).

Substances. Suicide.

Page 11: The psychiatric case note.

Developmental I: the family players.

Geno-gram.Age, job.Support, conflict.Isolation or support

Page 12: The psychiatric case note.

Developmental II: Life history.

InfancyEarly childhood.Primary schoolSecondary schoolTraining / University.WorkRelationships.

Page 13: The psychiatric case note.

Developmental III: personality.

Usual (premorbid) personality.Percieved strengths & weaknesses.Hobbies, interests.Methods of coping. Loss Stress Current situation.

What supports & strengths currently accessible.

Page 14: The psychiatric case note.

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)

Page 15: The psychiatric case note.

[Physical examination.]

Nutrition (Height, weight. BMI)Cardiorespiratory, (pulse, BP)CirculationNeurological(abdominal and g-u very rarely, usually referred).

Page 16: The psychiatric case note.

Mental State Examination.

“BOTAMI”BehaviorOrientationTalk and ThoughtAffectMood Insight and Judgement.

Page 17: The psychiatric case note.

Behaviour.

“Three As”.AppearanceActivity. Specific comment extra-pyridoxal side-

effects “EPS”. Comment if responding non-apparent

stimuli (“NAS”) i.e.. Hallucinating.

Attitude Rapport.

Page 18: The psychiatric case note.

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).

Page 19: The psychiatric case note.

[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).

Page 20: The psychiatric case note.

Talk

Rate & Flow Normal, Staccato Laconic. Over inclusive Mute

Prosody

Page 21: The psychiatric case note.

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.

Page 22: The psychiatric case note.

Affect

RangeMobility. Restricted Labile

“affect is weather, mood is climate”.

Page 23: The psychiatric case note.

Mood

Rich vocabulary mood states. Angry Sad Anxious Happy…

Technical terms. Hypomanic never involves psychotic

symptoms. Dysphoria implies does not currently meet

criteria depression.

Page 24: The psychiatric case note.

Insight

Comprehend Information you provide & other

sources.

Cognitively process Impaired by defence mechanisms.

Communicate Choices to you.

Page 25: The psychiatric case note.

[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.

Page 26: The psychiatric case note.

[Defense mech II]

Image distortion, minor Devaluation, idealising, omnipotence

Disavowal Denial, projection, rationalisation.

Image distortion, major Autistic fantasy, projective

identification, splitting (self image, others)

Page 27: The psychiatric case note.

[Defense mech III]

Action Acting out, apathetic withdrawal,

help-rejection complaining, passive regression.

Defensive dysregulation Delusional projection, psychotic

denial, psychotic distortion.

Page 28: The psychiatric case note.

Judgement

Ability to understand consequences actions.ANDAbility to take responsibility for actions.

Page 29: The psychiatric case note.

Formulation (psychiatric)

1. Summary sentence presentation.2. Predisposing factors3. Precipitating factors4. Perpetuating factors.[Choice of model flows from

problem]

Page 30: The psychiatric case note.

Diagnosis

DSM Axes1. Psychiatric syndrome2. Personality3. Medical condition4. Social stressors5. Level of function.

Page 31: The psychiatric case note.

Plan.Place of care Risk management (suicide, self harm, harm others) Use inpatient, respite, MHA.

Biomedical Investigations. Medications ECT, light therapy.

PsychologicalSocial Risk management (money, child care etc). Functional assessment & rehabilitation.

Page 32: The psychiatric case note.

Assessment Write up.

Traditionally 5-6 sheets A4, or 2-4 pages typed. Plan followed opinion (driven by

doctor). Risk loss previous knowledge.

Page 33: The psychiatric case note.

Traditional note or letter.

Process of interview.Content of interviewAssessmentInterventionsOngoing plan.

Page 34: The psychiatric case note.

Psychotherapy “process” note.

Dynamic Narrative. Defences and Transference Interpretations.

Structured. Plan / protocol session. Adherence / homework Process of session. Homework Plan next session.

Page 35: The psychiatric case note.

Psychopharm progress note.

Process interview.Symptoms including side-effectsLevel of functionFocused mental state.Relevant investigations.Medication changes / current medications.

Page 36: The psychiatric case note.

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.

Page 37: The psychiatric case note.

[Problem orientated medical record]

Invented in 1970s.Database (initial assessment & investigations.Problem list.Plan.

Page 38: The psychiatric case note.

[Problem orientated progress notes.]

List of active problems.For each problem “SOAP” Subjective Objective (MSE findings, outcome

scales etc). Assess Plan

Page 39: The psychiatric case note.

Thank you