Mental Health Documentation Principles
Mental health documentation requires sensitivity, precision, and thoroughness. Your notes must capture the patient's mental state, support clinical decision-making, ensure safety, and meet legal requirements — all while maintaining the patient's dignity.
The Mental Status Exam (MSE)
The MSE is the psychiatric equivalent of the physical exam. It provides an objective snapshot of the patient's mental functioning at the time of evaluation.
**Components:**
• **Appearance**: Grooming, hygiene, dress, age appearance
• **Behavior**: Psychomotor activity, eye contact, cooperation
• **Speech**: Rate, rhythm, volume, tone
• **Mood**: Patient's subjective emotional state (in their words)
• **Affect**: Observed emotional expression (range, congruence, stability)
• **Thought Process**: Organization, coherence, logic
• **Thought Content**: Delusions, obsessions, preoccupations
• **Perceptions**: Hallucinations (auditory, visual, other)
• **Cognition**: Orientation, attention, memory
• **Insight**: Understanding of illness
• **Judgment**: Decision-making ability
📋 MSE Documentation Example
**Mental Status Exam:**
• **Appearance**: 34 y/o female appearing stated age, disheveled, poor hygiene, wearing wrinkled clothing
• **Behavior**: Psychomotor retardation, poor eye contact, cooperative but slow to respond
• **Speech**: Soft, slow rate, monotone
• **Mood**: "Empty" (patient's words)
• **Affect**: Flat, constricted range, mood-congruent
• **Thought Process**: Linear, goal-directed, impoverished content
• **Thought Content**: Passive SI ("I wish I wouldn't wake up"), no active plan, no HI, no delusions
• **Perceptions**: Denies AH/VH
• **Cognition**: Alert, oriented x4, attention intact
• **Insight**: Fair — recognizes depression has worsened
• **Judgment**: Impaired — stopped medications 3 weeks agoSuicide Risk Assessment
Every mental health encounter requires suicide risk assessment. Document thoroughly:
**Key elements:**
• Suicidal ideation (passive vs. active)
• Plan (specific method, timeline)
• Intent (desire to act on thoughts)
• Means (access to method)
• Protective factors (reasons for living, social support)
• Risk factors (previous attempts, substance use, hopelessness)
• Risk level determination (low, moderate, high)
• Safety plan discussed
📋 Suicide Assessment Documentation
**Suicide Risk Assessment:** • **Ideation**: Active SI x 2 weeks, "I think about driving into traffic" • **Plan**: Has thought about overdose, no specific plan • **Intent**: Ambivalent — "Part of me wants to, part doesn't" • **Means**: Has access to medications at home • **Previous attempts**: One overdose attempt 2 years ago • **Protective factors**: Two children, religious beliefs against suicide • **Risk factors**: Recent job loss, divorce pending, alcohol use • **Risk Level**: MODERATE-HIGH • **Safety Plan**: Discussed and documented, emergency contacts identified, means restriction counseled (remove medications from home)
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Depression Screening Documentation
Use standardized tools and document scores: • PHQ-9 score: 18 (moderately severe depression) • GAD-7 score: 12 (moderate anxiety) • Columbia Suicide Severity Rating Scale: Positive for ideation, negative for behavior Scores provide objective data and track treatment response over time.
Documenting Psychosis
When documenting psychotic symptoms:
- •Quote hallucination content exactly when possible
- •Specify type: auditory, visual, tactile, olfactory
- •Note if command hallucinations are present
- •Document delusion type: paranoid, grandiose, somatic, etc.
- •Assess insight into symptoms
- •Document reality testing ability
- •Note impact on functioning and safety
Capacity and Competency
Document decision-making capacity when relevant:
**Four components of capacity:**
1. **Understanding**: Can explain the condition and treatment options
2. **Appreciation**: Recognizes how information applies to their situation
3. **Reasoning**: Can weigh risks and benefits
4. **Choice**: Can communicate a consistent decision
Document your assessment of each component when capacity is in question.
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Involuntary Hold Documentation
When initiating an involuntary psychiatric hold, document: • Specific danger to self or others (with examples) • Inability to care for self due to mental illness • Less restrictive alternatives considered and why insufficient • Patient's statements supporting the hold • Time hold initiated and who was notified • Patient rights provided This documentation has significant legal implications — be thorough and specific.