Although people should have access to their records, a LOT of unnecessary worry is created because medical terminology is so precise and easy to misinterpret by people. A lot of my and my patients' time is now wasted by questioning of mental status exam elements, billing codes, diagnoses, etc. If you trust this doc, I'd say lay off reading the notes. This MSE is perfectly fine. I would say even more involved than what most docs do, indicative of someone taking time and thought in their work. More on reddit.com

Never trust these CE doctors. They are liars and don’t report the truth back to SSA. More on reddit.com

It varies based on where you work. The Psychiatric Interview by Carlat is a wonderful resource for the varied aspects of assessment within the psychiatric setting. In addition, it provides tips for addressing specific situations (e.g. pediatric patient not wanting to open up). The book is geared towards providers, but it is still a great read for psychiatric nurses. A "quick and dirty" MSE is comprised of 3 questions. How are you feeling? Mood should always be documented in quotes. This is the patient's subjective experience, and we can not infer this without asking. 2. Are you having any thoughts of killing yourself or others? Some people prefer to say harming, but best practice is to say killing. The interpretation of the word harm can exclude SI / HI, and you could miss a red flag by asking the question that way. 3. Are you seeing or hearing things others don't see or hear? Quick check for hallucinations. Their response does not mean psychosis is not present. Patients often withhold this information, particularly if you have no rapport with them. Every other item for the MSE (e.g., appearance, dress, affect, etc.) can be observed during this brief assessment. Of course, you may need to ask additional questions depending on how the patient responds. Doing the assessment isn't as difficult as learning how to document your findings. Take the time to learn psychiatric-specific terminology (e.g. neologisms, word salad, tangential speech, etc.). Edit: I saw you were seeking input on critical thinking within the geriatric psych setting. Review the difference in presentation for psychosis, delirium, and dementia in this population. If symptoms had sudden / severe onset without a psychiatric history, it's likely delirium secondary to an organic problem (e.g. infection or medication changes). More on reddit.com

What's being evaluated at the Mental Health Psych Exam is shown on this SSA form: Mental Health Functional Capacity Report: https://www.ssdfacts.com/forms/SSA-4734-F4-SUP.pdf Usually, it doesn't take long to gather the info as it's a Clinical assessment of Psych Functionality oriented around basics: Memory, Understanding, Concentrating, Social Interaction and Adaptation. The physician uses a cleverly structured brief conversation to address it all. More on reddit.com