The
patient’s mood [how the patient tells you they’re feeling-is described as
anxious/depressed/crawling out of their skin/etc.]. The patient’s affect [what you
observe-appears anxious/depressed/flattened/blunted/restricted/exaggerated]
which is [congruent/incongruent] with their reported mood. Patient noted to be [making good/poor eye
contact/frequently looking down/away].
Patient [was/was not] noted to be attending to internal stimuli
[specify/with patient noted to be conversing in an empty room/etc.]. The patient’s thought process is noted to be
[organized/disorganized with/without delusions/obsessions]. The patient’s speech [is noted to be
unremarkable/notable for pressured speech/inappropriately loud/soft given size
of the room and distance apart/tangential speech/etc.]. The patient was noted to be [well kempt and
groomed/disheveled/encrusted with urine and feces].
The patient was noted to be expressing
[suicidal thoughts with/without reported plan/no suicidal or homicidal thoughts
or plan at this time]. The patient [reported/denied] hallucinations [described as auditory/visual].
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