psychiatric medical record, Psychiatric Medical Record

The Psychiatric Medical Record includes:

Entry Reason

Present Disease

  • Symptoms & recording of life events

    • Family - Hereditary History

  • Father – mother - siblings husband/wife - children
  • Other relatives - twins

    • Previous Health Status

  • Childhood diseases - Venereal diseases
  • Imports to hospital - operations
  • Injuries-bruises
  • Drug Use
  • Allergies

    • Personal and Social History

  • Place of birth - accomodation
  • Labour - birth conditions
  • First years of development (walking, speaking, clamping control, with whom he grew up)
  • Composition of the family
  • Family relationships
  • (description of the patient)
  • (description of relatives)
  • Childhood
  • Σχολική περίοδος
  • Puberty
  • Σεξουαλικές τάσεις και εμπειρίες
  • Gynecological history
  • Military service
  • Marriage
  • Professional employment
  • Religion - Education -Employment
  • Hobbies - pets
  • Use of substances - addictions

    • Description of Personality

  • How the sick man describes himself
  • How the others describe him

    • Personal Commemorative (by systems)

  • general
  • skin
  • head-cervix
  • eyes
  • ears-nose-mouth-pharynx
  • breasts
  • respiratory
  • cardiovascular
  • digestive tract
  • haematopoietic - lymph nodes
  • urinary tract
  • overhead
  • nervous

    • Personal Psychiatric Background

    SIGNIFICANT INVESTIGATION
  • Behavioral note
  • Appearance - Facial expression - Stage during examination
  • Elements from daily (individual and social) life
  • Body care / clamp control
  • Diet - sleep - sexual behavior
  • Family - social - professional life suicidal-aggressive tendencies
  • Semiology of the present mental activity
  • Range and clarity of consciousness - self consciousness
  • Orientation in space / time - attention-concentration
  • Memory
  • Judgement
  • thought (flow-content)
  • Perception
  • Emotion
  • Will and psychomotor

    • Objective Examination

  • VITAL POINTS:
    • Temperature -heartbeats-breaths
  • OVERALL IMPRESSION:
    • Diaphragm-View-Nutrition-Height-Weight-BMI (Body Mass Index) Bedridden/ambulatory
  • PSYCHODIANOTIVE SITUATION:
    • Good/Bad informant Emotional - indolent - confusing - comatose attention - orientation - memory - speech difficulty
  • SKIN:
    • Hue- turgidity - hair loss - rashes etc
  • HEAD:
    • Eyes - Nose - ears - mouth - pharynx
  • NECKING:
    • Movements -thyroid - trachea - lymph nodes - big vessels

    Objective Examination II

  • BODY:
  • UPPER LIMBS:
    • Hands - palms - fingers - nails - muscle strength - joints - vessels
  • LEGS:
    • Edge - soles - fingers - claws - hammers - gastropneumonia - muscle strength - joints - vessels
  • BREASTS:
  • LYMPH NODES:
    • Cervical - supergy - axillary - inguinal - others

    Objective Examination III

  • RESPIRATORY:
    • Overview - attack - palpation - hearing
  • CARDIOVASCULAR:
    • Heart: thrust-tones-blasts-roots Vessels: heartbeats - blastings
  • ABDOMEN:
    • Overview - attack - palpation - hearing Liver - spleen - kidney Finger examination
  • ΟΥΡΟΠΟΙΟΓΕΝΝΗΤΙΚΟ
  • UROPIOGENEAN MUSCULATION:
    • Muscle tone - muscle power joints
  • NERVOUS SYSTEM:
    • Consciousness - Communication - Orientation - Attitude - Buddhism Sensibility - mobility - Brain conjugations - cerebellum
     

    Expression of Interest

     
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