Benchmark Mental Status EXAM (MSE) Report 521 PDF

Preview

Summary

Download Benchmark Mental Status EXAM (MSE) Report 521 PDF

Description

BENCHMARK MENTAL STATUS EXAM REPORT 1

Benchmark Mental Status Exam Report

Cara Soto School of Behavioral Sciences in Mental Health Counseling, Liberty University

Author Note Cara Soto I have no known conflict of interest to disclose. Correspondence concerning this article should be addressed to Cara Soto Email: [email protected]

BENCHMARK MENTAL STATUS EXAM REPORT 2 Benchmark Mental Status Exam Report Elizabeth Smith is an energetic Caucasian woman about 5'5". She comes into the office with a smile and is friendly. She has a pleasant face, and she is average weight for her stature. In this interview she presented herself as composed and confident yet welcoming and calm. Her clothing was clean and professional. Her hair was pulled back in a sweep. Her movement during the interview was smooth and normal. She did touch her face with her hand quite a few times. However, no unusual ticks or movements were noticed. She walked into the office with ease and sat down after shaking counselor's hand and using words of greeting. She filled out the intake form completely and effectively answering all question. Her speech was coherent, and she answered all questions with complete sentences, using references from outside sources for material being discussed. Her attitude during the evaluation was cooperative. She stayed on topic. Client was pleasant throughout the exam. She answered how an educated person with her level of education would answer, with intelligence and confidence. When she didn't understand a question, she would ask for it to be repeated, and then she would rephrase to make sure she understood. This demonstrates good listening skills. Elizabeth is articulate. She had no difficulty remembering a recent event and when asked to recount a news event that happened five or more years ago, she did so with ease. She is in normal range of memory recall. She uses her hands as she is talked to express herself. She used eye contact when the counselor was speaking. When she was speaking, she did make eye contact but also would look away as she pondered an idea or tried to answer a question and then would re-engage with eye contact. Elizabeth has normal to exceptional interpersonal skills. Elizabeth’s thought process was coherent. She was alert and oriented X5. She was coherent throughout the session. She was not distracted as we talked. She demonstrated high

BENCHMARK MENTAL STATUS EXAM REPORT 3 concentration and attention to what was happening during the assessment. Elizabeth’s thought process was connected and had flow. She stated that she has never been delusional, struggled with obsessions or preoccupations. She said she has never been on psychotropic medications. Elizabeth stated that her thought process has never included homicidal or suicidal ideation. Elizabeth did not indicate any attempts of violence, nor did she talk of any violence or harm towards self or others. No racing thoughts were noticed. There appears to be no depression or mental health condition that prevents her from making sound judgment. During her examination she was read a short example of what could happen in a dorm situation when two girls disagreed and asked to problem solve. She also had insight to the question and used logic and reason to solve the problem and was creative in doing so. Abstraction skills were normal. Elizabeth was read a short story about a young girl and her grandmother. She showed compassion and concern for the child in the story. She demonstrated normal affect. She quickly gained rapport with the counselor by demonstrating empathy and she related the story to her own story of when she was a child. When entering the office for her evaluation Elizabeth was calm and acted comfortable yet professional. Facial and emotional responses reflect normal reaction to items being discussed. Elizabeth has a history of sound money management and an excellent academic history. She is financially stable and has been accepted into the Liberty University Clinical Psychology program. From the evaluation Elizabeth is emotionally and mentally stable. She has acceptable judgment when comes to problem solving, she demonstrates clear and articulate thoughts. She is self-regulated and has high impulse control. Orientation and affect are all in normal range. Elizabeth also demonstrates a positive relationship to spiritual matters....