Wiki Pysch Exam

[dawn1170]

Would someone assist me with the elements in a pysch exam below is what was documented:
Appearance:WNL
Behavior: Immature Easily distracted
Afffect:Blunted
Mood:Congruent with affect
Eye contactoor
Motor:WNL
insight: insight lacking
Judgement: impaired
Reliablity:impaired
Speech:Non-verbal
Orientationassage of time

This is different than what I have printed from the 1997 Specialty exam for Pysch

 

[smdumpert]

Is that the whole note?

 

[dawn1170]

No, that was just what the provider documented for the exam.

 

[mitchellde]

While he does not need to follow the bullets in the 97 guidelines he does need to document much more to determine if a bullet is met, the WNL for appearance I would not count as it tells us nothing about the true appearance of this patient, what is normal?
you get a bullet for mood and affect
a bullet for behavior
insite and judgement and reliability I gave no credit as it needs further description
WNL for motor does not count
and orientation needs a better descriptive.
so being rather generous I give it 2 bullets for exam.

 

[GaPeach77]

Here is a link for a psych exam coding tool for 97 guidelines.

http://emuniversity.com/SpecialtyExams.html

 

[dawn1170]

thank you everyone for the help