Palmetto GBA - South Carolina Part B Carrier

Exam: Psychiatric

Content & Documentation Requirements
Level of Exam	Perform and Document
Problem Focused	One to five elements identified by a bullet.
Expanded Problem Focused	At least six elements identified by a bullet.
Detailed	At least nine elements identified by a bullet.
Comprehensive	Perform all elements identified by a bullet Document every element in a box with a shaded border Document at least one element in each box with an unshaded border

System/Body Area	Elements of Examination
Constitutional *All elements must be documented.	Measurement of any three of the following seven vital signs: Sitting or standing blood pressure Supine blood pressure Pulse rate and regularity Respiration Temperature Height Weight (may be measured and recorded by ancillary staff) General appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)
Musculoskeletal	Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements Examination of gait and station
Psychiatric *All elements must be documented.	Description of speech including: rate, volume, articulation, coherence, and spontaneity with notation of abnormalities (e.g., perseveration, paucity of language) Description of thought processes including: rate of thoughts, content of thoughts (e.g., logical vs. illogical, tangential), abstract reasoning, and computation Description of associations (e.g., loose, tangential, circumstantial, intact) Description of abnormal or psychotic thoughts including: hallucinations, delusions, preoccupation with violence, homicidal or suicidal ideation, and obsessions Description of the patient’s judgment (e.g., concerning everyday activities and social situations) and insight (e.g., concerning psychiatric condition) Complete mental status examination including: Orientation to time, place and person Recent and remote memory Attention span and concentration Language (e.g., naming objects, repeating phrases) Fund of knowledge (e.g., awareness of current events, past history, vocabulary) Mood and affect (e.g., depression, anxiety, agitation, hypomania, lability)

System/Body Area

Elements of Examination

Constitutional

*All elements must be documented.

Measurement of any three of the following seven vital signs:
- Sitting or standing blood pressure
- Supine blood pressure
- Pulse rate and regularity
- Respiration
- Temperature
- Height
- Weight (may be measured and recorded by ancillary staff)
General appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)

Musculoskeletal

Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements
Examination of gait and station

Psychiatric

*All elements must be documented.

Description of speech including: rate, volume, articulation, coherence, and spontaneity with notation of abnormalities (e.g., perseveration, paucity of language)
Description of thought processes including: rate of thoughts, content of thoughts (e.g., logical vs. illogical, tangential), abstract reasoning, and computation
Description of associations (e.g., loose, tangential, circumstantial, intact)
Description of abnormal or psychotic thoughts including: hallucinations, delusions, preoccupation with violence, homicidal or suicidal ideation, and obsessions
Description of the patient’s judgment (e.g., concerning everyday activities and social situations) and insight (e.g., concerning psychiatric condition)

Complete mental status examination including:

Orientation to time, place and person
Recent and remote memory
Attention span and concentration
Language (e.g., naming objects, repeating phrases)
Fund of knowledge (e.g., awareness of current events, past history, vocabulary)
Mood and affect (e.g., depression, anxiety, agitation, hypomania, lability)

last updated on 09/25/2009

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