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Old 07-23-2012
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Smile Depression Case Patient Note

is this ok for the note in a depressed pt??


pt looks unkept, in low moood, is cooperative, fluent in speech.thoguth process insigh , judgement inact.

heent: no thyromegaly, bruit
neuro: mmse:a&o x 3,registrstion, recall, attention and caltulation intact.follows 3 step command.
cn: 2-10-intact, motor: 5/5 throughout, sensory: intact bilaterally, dtr: 2+ throughout,gait: normal
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  #2  
Old 07-23-2012
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Quote:
Originally Posted by heman466s View Post
is this ok for the note in a depressed pt??


pt looks unkept, in low moood, is cooperative, fluent in speech.thoguth process insigh , judgement inact.
General: Pt looks unkept, in low mood, cooperative, fluent in speech. Thought-processing, insight, and judgement are intact.

heent: no thyromegaly, bruit
HEENT: Heat AT/NC, Supple Neck, Ears N, Throat N, No thyromegaly, no bruits

neuro: mmse:a&o x 3,registrstion, recall, attention and caltulation intact.follows 3 step command.
CNS: MMSE; A&O X3; Registration, Recall, Attention, and Calculation intact. Follows 3 Step command.

cn: 2-10-intact, motor: 5/5 throughout, sensory: intact bilaterally, dtr: 2+ throughout,gait: normal
CN: 2-10 Intact, Motor: 5/5 all extremities, Intact sensation, DTR: ++ in knees and ankles, Gait: Normal
Look at my corrections in green.

Appropriate punctuation, capitalization of abbreviations, and correct spelling as much as you can, will impress the reader and will make your chances of passing higher. You had many mistakes in these, pay attention to the corrections I made.

You need to also mention quickly about CVS, Resp, Abdomen, and Skin.

As far as speech it's important to to mention normal paced or slow (as we are dealing with depression).

Mini Mental Exam should be detailed in a case of depression (or any psychiatric case), you did a good job in that but it can be more detailed.

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