Week 2: Lecture Proper (RLE) Flashcards
a state of well-being where there is the ability to deal with
the typical stresses of life, works productively, and
contribute to their community.
MENTAL HEALTH
may modify reality, influence daily living, or harm
judgment
MENTAL ILLNESS
the main reason the patient is presenting, in their own
words
CHIEF COMPLAINT
the chronological account of what led up to the chief
complaint
HISTORY OF PRESENT ILLNESS
the history of all psychiatric or psychological concerns in
the past
PSYCHIATRIC HISTORY
listing all medical illnesses and listing all surgeries and
dates
MEDICAL OR SURGICAL HISTORY
All current and past medications, including the dose and
frequency
MEDICATION LIST
Any substances currently used and used in the past
● Method of use (oral, inhalation, injection, intranasal)
HISTORY OF ALCOHOL AND DRUG USE
under VIOLENCE RISK ASSESSMENT
Suicidal Ideation
Homicidal Risk
Abuse
ABUSE ASSESSMENT
In the past year, have you been hit, kicked, or physically
hurt by another person?
provides clues as to how the person interacts with others
SOCIAL HISTORY
important because many mental illnesses are hereditary
FAMILY HISTORY
Commonly genetic mental illnesses include
depression, bipolar disease, schizophrenia, and
attention deficit disorder.
Record the patient’s current employment status and
occupation
OCCUPATIONAL HISTORY
will help the nurse understand the best way to interact with
the patient
EDUCATIONAL HISTORY
Determine if the patient has legal trouble, probation,
parole, pending charges, or incarcerated.
LEGAL HISTORY