The BH - Mental Status Exam template is part of the assessment process (Comprehensive Assessment and Psychiatric Evaluation). The provider’s observations of behavior and assessments of mental health symptoms can be documented here. The Mental Status exam can be completed at every visit and do not copy forward onto future encounters.
- In the Mental Status Evaluation panel, select the Mental Status Exam link.
The BH - Mental Status Exam template appears.
- The General Observations panel includes the option to select Generally normal for all of the areas presented.
- You can select this option and still choose specific items under each area to indicate traits observed for this client.
- If appropriate, select one or more options for each area within the panel.
- To chart by exception on the remaining panels, select the Unremarkable option to populate the first checkbox for each section (except Hallucinations, on which both Denied and None evidenced are selected).
- Choose another option in any of the sections within the panel.
This action clears the first checkbox within that section. This action also removes the check mark from Unremarkable.
- On the Summary panel, free text or dictate information into the Elaboration on positive mental status findings memo field.
- Select Save & Close.
- To return to the previous template without saving the exam findings, select Cancel.
