Identifying Data
Affect
Thought Content
Thought Process
PerceptualDisturbances
100

Highest grade level completed in school

What is educational level?

100

Outward emotional expression consistent with mood

What is mood congruence?

100

Expressing ideas of harming oneself

What is suicidal ideation?

100

Verbalizations are continuous and rapid and flow from one to another

What is flight of ideas?

100

The individual is seeing things that do not exist

What is a visual hallucination?

200

What is your preferred gender pronoun?

Gender identity

200

Minimal outward emotional expression observed

What is constricted or blunted?

200

Expressing ideas of harming others

What is homicidal ideation?

200

Verbalizations are lengthy and tedious, full of detail, delayed in reaching the end point.

What is circumstantiality?

200

The patient is having unrealistic sensations on the skin

What is tactile hallucination?

300

With whom do you share your home?

What are living arrangements?

300

There is an absence of outward emotional expression

What is flat?

300

Persistent thought or feeling that s/he is unable to eliminate from consciousness?

What is an obsession?

300

Verbalizations are lengthy and tedious and never reach the end point

What is tangentiality?

300

The most common type of hallucination

What is a auditory hallucination?

400
Seasonal, medical, dietary

What are allergies?

400

The outward emotional expression is what would be expected in a certain situation

What is appropriate?

400

Person is speaking in a way that indicates that the words or actions have special power

What is magical thinking?

400

Persistently repeating what the other person says

What is echolalia?

400

Patient verbalizes that the environment feels strange and unreal, feels that the environment has changed

What is derealization?

500

How can we best help you today?

What is the chief complaint?

500

The outward emotional expression is incompatible with the situation

What is inappropriate?

500

Little information is conveyed because of vagueness or stereotypical statements or cliches

What is poverty of content?

500

Nurse: "George, it is time to go to lunch."

George: "lunch, lunch, lunch"

What is preservation?

500

The patient verbalizes feeling outside their body, has an altered sense of self

What is depersonalization?

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