Immediately Available Record of Mental Status Exam

Abstract

DESPITE the obvious importance of an accurate and systematic record of the results of a mental status examination of the psychiatric patient, the usual record in hospitals and outpatient clinics is far from satisfactory. First of all, there is great variability among different examiners in the areas of psychopathology explored and little systematization in the manner in which the results are recorded. Thus, in reading the usual record, it is impossible to know whether the failure to note an area of psychopathology is because (1) the patient was examined in this area but no psychopathology was observed, (2) psychopathology was present but deemed not significant enough to mention, or (3) the area was not explored. For these reasons, the usual record of the mental status examination has proved to be totally inadequate for subsequent research studies. In addition, usually there is a