분야
hwp1.일반적 정보(General Information)
2. 주호소(Chief Complaint)
3. 현병력(History of Present Illness)
4. 과거력(Past History)
1) Medical
2) Psychiatric
5. 가 족 력(Family History)
6. 사회력(Social History)
1) Personal / Developmental
2) Health related Habits
7. Mental Status Examination
Mental Status Examination
1) General Appearance
2) Behavior and acivity
3) Attitude to examiner
4) Speech
5) Mood and Affect
6) Perception
7) Thoughts
(1)Thought form & process
(2)Thought content
8) Sensorium / Cognition
9) Judgement
10) Insight
11) Reliability
8. 신체사정(Physical Examination)
1) Vital Sign
2) Sleep
3) Oral Intake
4) Elimination
5) Drug Side Effects
6) Other Physical Problems
9. 심리검사(Psychometry) 및 임상 검사(Clinical Lab) 결과
10. 의학적 진단
11. 의학적 치료
12. 간호 과정
Mental Status Examination
1) General Appearance
(1)입원시 상태: 묶여서 왔는지□, 도보□, wheel chair□, stretch car(ER)■
(2)자발적 입원여부: Yes□, No■
(3)외모: 체구, 신장, 옷차림새, 두발상태, 화장상태(여자)
보통키, 건장한 체격, 짧은 머리의 구릿빛 얼굴의 남환
(4)personal hygiene: good■, poor□ (so so)
(5)facial expression: blunted□, tense■, bright□, angry□, deperessive□
(6)posture; rigid□, slumped□, comfortable■, others:
(7)eye contact: Yes■, No□
2) Behavior and acivity
stereotypy□, mannerism□, rigid□, hyperactivity□, tremor□, retarded□, psychomotor agitation■, compulsive act□, others:
3) Attitude to examiner
cooperative□, submissive□, defensive□. apathetic□, hostile■,
others:
4) Speech
(1)spontaneity: +□, -■
(2)Verbal productivity: increased□, decreased□, normal■, talkative□,
others:
(3)Speed: rapid□, slow□, others: normal
(4)Pich(음의 고저): high □, low □, normal ■
(5)Tone: loud□, whispered□, monotonous□, normaly■
(6)Speech disturbance: dysarthria□, poverty of speech□, stammering(말더듬)□, mumbled, others: 없음