I. GENERAL HISTORY OF PATIENT

Name______________Age______________Sex ______________

Racial and ethnic data ______________

Marital status ______________

Number and ages of children/siblings

Living arrangements ______________

Occupation ______________

Education ______________

Religious affiliations ______________

II. PRESENTING PROBLEM

B. Recent difficulties/alterations in:

2. Usual level of functioning

3. Behavior

4. Perceptions or cognitive abilities

C. Increased feelings of:

2. Anxiety

3. Hopelessness

4. Being overwhelmed

5. Suspiciousness

6. Confusion

D. Somatic changes, such as:

2. Insomnia

3. Lethargy

4. Weight loss or gain

5. Palpitations

III. RELEVANT HISTORY—PERSONAL

B. Educational background ______________

C. Occupational background ______________

2. How long at that job? ______________

3. Previous positions and reasons for leaving ______________

4. Special skills ______________

D. Social patterns

2. Describe a usual day ______________

E. Sexual patterns

2. Sexual orientation ______________

3. Sexual difficulties ______________

4. Practice safe sex or birth control? ______________

F. Interests and abilities

2. What is the patient good at? ______________

3. What gives the patient pleasure? ______________

G. Substance use and abuse

2. Any herbal or over-the-counter medications? ______________
How often? ______________ How much? ______________

3. What psychotropic drugs does the patient take? ______________
How often? ______________ How much? ______________

4. How many drinks of alcohol does the patient take per day? ______________ Per week? ______________

5. Does the patient identify use of drugs as a problem? ______________

H. How does the patient cope with stress? ______________

2. Who can the patient talk to? ______________

3. What usually helps to relieve stress? ______________

4. What did the patient try this time? ______________

IV. RELEVANT HISTORY—FAMILY

2. Was there physical or sexual abuse? ______________

3. Did the parents drink or use drugs? ______________

4. Who was in the home when the patient was growing up? ______________

B. Adolescence

2. Describe the patient’s peer group at that time. ______________

C. Use of drugs

2. What was the effect on the family? ______________

D. Family physical or mental problems

2. Who in the family had physical or mental problems? ______________

3. Describe the problems. ______________

4. How did it affect the family? ______________

E. Was there an unusual or outstanding event the patient would like to mention? ______________

2. MENTAL AND EMOTIONAL STATUS

B. Behavior
Restless ______________ Agitated
______________ Lethargic ______________
Mannerisms ______________
Facial expressions ______________
Other ______________

C. Speech
Clear ______________ Mumbled
______________ Rapid ______________
Slurred ______________
Constant ______________
Mute or silent ______________
Barriers to communications ______________
Specify (e.g., patient has delusions or is confused, withdrawn, or verbose) ______________

D. Mood
What mood does the patient convey? ______________

E. Affect
Is the patient’s affect bland, apathetic, dramatic, bizarre, or appropriate? Describe ______________

F. Thought process

2. Cognitive ability
Proverbs: Concrete ______________
Abstract ______________
Serial sevens: How far does the patient go? ______________
Can the patient do simple math? ______________
What seems to be the reason for poor concentration? ______________
Orientation to time (?), place (?), person (?) ______________

G. Thought content

2. Self-concept: How does the patient view himself or herself? ______________
What does the patient want to change about himself or herself? ______________

3. Insight: Does the patient realistically assess his or her symptoms? ______________
Realistically appraise his or her situation. ______________ Describe ______________

4. Suicidal or homicidal ideation? ______________
What is suicide potential? ______________
Family history of suicide or homicide attempt or successful completion? ______________ Explain ______________
Preoccupations. Does the patient have hallucinations? ______________ Delusions? ______________ Obsessions? ______________
Rituals? ______________
Phobias? ______________
Grandiosity? ______________
Religiosity? ______________
Worthlessness? ______________
Describe ______________

ASK PATIENT:

I. Cultural influences
With what cultural group do you identify? ______________
Have you tried any cultural remedies or practices for your condition? If so, what? ______________
Do you use any alternative or complementary medicines/herbs/practices? ______________

Adapted from Varcarolis, E. M. (2002). Foundations of psychiatric mental health nursing (4th ed.). Philadelphia: Saunders, pp. 203-205; reprinted by permission.

Sedentary Lifestyle (00168)

Class 2: Health Management

Risk-Prone Health Behavior (00188)

Ineffective Health Maintenance (00099)

Readiness for Enhanced Immunization Status (00186)

Ineffective Protection (00043)

Ineffective Self-Health Management (00078)

Readiness for Enhanced Self-Health Management (00162)

Ineffective Family Therapeutic Regimen Management (00080)

Ineffective Infant Feeding Pattern (00107)

Imbalanced Nutrition: Less Than Body Requirements (00002)

Imbalanced Nutrition: More Than Body Requirements (00001)

Readiness for Enhanced Nutrition (00163)

Risk for Imbalanced Nutrition: More Than Body Requirements (00003)

Impaired Swallowing (00103)

Class 2: Digestion

Class 3: Absorption

Class 4: Metabolism

Neonatal Jaundice (00194)

Risk for Neonatal Jaundice (00230)

Risk for Impaired Liver Function (00178)

Class 5: Hydration

Readiness for Enhanced Fluid Balance (00160)

Deficient Fluid Volume (00027)

Excess Fluid Volume (00026)

Risk for Deficient Fluid Volume (00028)

Risk for Imbalanced Fluid Volume (00025)

Overflow Urinary Incontinence (00176)

Reflex Urinary Incontinence (00018)

Stress Urinary Incontinence (00017)

Urge Urinary Incontinence (00019)

Risk for Urge Urinary Incontinence (00022)

Impaired Urinary Elimination (00016)

Readiness for Enhanced Urinary Elimination (00166)

Urinary Retention (00023)

Class 2: Gastrointestinal Function

Perceived Constipation (00012)

Risk for Constipation (00015)

Diarrhea (00013)

Dysfunctional Gastrointestinal Motility (00196)

Risk for Dysfunctional Gastrointestinal Motility (00197)

Bowel Incontinence (00014)

Class 3: Integumentary Function

Class 4: Respiratory Function

Sleep Deprivation (00096)

Readiness for Enhanced Sleep (00165)

Disturbed Sleep Pattern (00198)

Class 2: Activity/Exercise

Impaired Bed Mobility (00091)

Impaired Physical Mobility (00085)

Impaired Wheelchair Mobility (00089)

Impaired Transfer Ability (00090)

Impaired Walking (00088)

Class 3: Energy Balance

Fatigue (00093)

Wandering (00154)

Class 4: Cardiovascular/Pulmonary Responses

Risk for Activity Intolerance (00094)

Ineffective Breathing Pattern (00032)

Decreased Cardiac Output (00029)

Risk for Ineffective Gastrointestinal Perfusion (00202)

Risk for Ineffective Renal Perfusion (00203)

Impaired Spontaneous Ventilation (00033)

Ineffective Peripheral Tissue Perfusion (00204)

Risk for Decreased Cardiac Tissue Perfusion (00200)

Risk for Ineffective Cerebral Tissue Perfusion (00201)

Risk for Ineffective Peripheral Tissue Perfusion (00228)

Dysfunctional Ventilatory Weaning Response (00034)

Class 5: Self-Care

Readiness for Enhanced Self-Care (00182)

Bathing Self-Care Deficit (00108)

Dressing Self-Care Deficit (00109)

Feeding Self-Care Deficit (00102)

Toileting Self-Care Deficit (00110)

Self-Neglect (00193)

Class 2: Orientation

Class 3: Sensation/Perception

Class 4: Cognition

Chronic Confusion (00129)

Risk for Acute Confusion (00173)

Ineffective Impulse Control (00222)

Deficient Knowledge (00126)

Readiness for Enhanced Knowledge (00161)

Impaired Memory (00131)

Class 5: Communication

Impaired Verbal Communication (00051)

Risk for Compromised Human Dignity (00174)

Risk for Loneliness (00054)

Disturbed Personal Identity (00121)

Risk for Disturbed Personal Identity (00225)

Readiness for Enhanced Self-Concept (00167)

Class 2: Self-Esteem

Situational Low Self-Esteem (00120)

Risk for Chronic Low Self-Esteem (00224)

Risk for Situational Low Self-Esteem (00153)

Class 3: Body Image

Interrupted Breastfeeding (00105)

Readiness for Enhanced Breastfeeding (00106)

Caregiver Role Strain (00061)

Risk for Caregiver Role Strain (00062)

Impaired Parenting (00056)

Readiness for Enhanced Parenting (00164)

Risk for Impaired Parenting (00057)

Class 2: Family Relationships

Dysfunctional Family Processes (00063)

Interrupted Family Processes (00060)

Readiness for Enhanced Family Processes (00159)

Class 3: Role Performance

Readiness for Enhanced Relationship (00207)

Risk for Ineffective Relationship (00229)

Parental Role Conflict (00064)

Ineffective Role Performance (00055)

Impaired Social Interaction (00052)

Class 2: Sexual Function

Ineffective Sexuality Pattern (00065)

Class 3: Reproduction

Readiness for Enhanced Childbearing Process (00208)

Risk for Ineffective Childbearing Process (00227)

Risk for Disturbed Maternal-Fetal Dyad (00209)

Risk for Post-Trauma Syndrome (00145)

Rape-Trauma Syndrome (00142)

Relocation Stress Syndrome (00114)

Risk for Relocation Stress Syndrome (00149)

Class 2: Coping Responses

Risk for Ineffective Activity Planning (00226)

Anxiety (00146)

Defensive Coping (00071)

Ineffective Coping (00069)

Readiness for Enhanced Coping (00158)

Ineffective Community Coping (00077)

Readiness for Enhanced Community Coping(00076)

Compromised Family Coping (00074)

Disabled Family Coping (00073)

Readiness for Enhanced Family Coping (00075)

Death Anxiety (00147)

Ineffective Denial (00072)

Adult Failure to Thrive (00101)

Fear (00148)

Grieving (00136)

Complicated Grieving (00135)

Risk for Complicated Grieving (00172)

Readiness for Enhanced Power (00187)

Powerlessness (00125)

Risk for Powerlessness (00152)

Impaired Individual Resilience (00210)

Readiness for Enhanced Resilience (00212)

Risk for Compromised Resilience (00211)

Chronic Sorrow (00137)

Stress Overload (00177)

Class 3: Neurobehavioral Stress

Risk for Autonomic Dysreflexia (00010)

Disorganized Infant Behavior (00116)

Readiness for Enhanced Organized Infant Behavior (00117)

Risk for Disorganized Infant Behavior (00115)

Decreased Intracranial Adaptive Capacity (00049)

Class 2: Beliefs

Class 3: Value/Belief/Action Congruence

Decisional Conflict (00083)

Moral Distress (00175)

Noncompliance (00079)

Impaired Religiosity (00169)

Readiness for Enhanced Religiosity (00171)

Risk for Impaired Religiosity (00170)

Spiritual Distress (00066)

Risk for Spiritual Distress (00067)

Class 2: Physical Injury

Risk for Aspiration (00039)

Risk for Bleeding (00206)

Impaired Dentition (00048)

Risk for Dry Eye (00219)

Risk for Falls (00155)

Risk for Injury (00035)

Impaired Oral Mucous Membrane (00045)

Risk for Perioperative Positioning Injury (00087)

Risk for Peripheral Neurovascular Dysfunction (00086)

Risk for Shock (00205)

Impaired Skin Integrity (00046)

Risk for Impaired Skin Integrity (00047)

Risk for Sudden Infant Death Syndrome (00156)

Risk for Suffocation (00036)

Delayed Surgical Recovery (00100)

Risk for Thermal Injury (00220)

Impaired Tissue Integrity (00044)

Risk for Trauma (00038)

Risk for Vascular Trauma (00213)

Class 3: Violence

Risk for Self-Directed Violence (00140)

Self-Mutilation (00151)

Risk for Self-Mutilation (00139)

Risk for Suicide (00150)

Class 4: Environmental Hazards

Risk for Contamination (00180)

Risk for Poisoning (00037)

Class 5: Defensive Processes

Latex Allergy Response (00041)

Risk for Allergy Response (00217)

Risk for Latex Allergy Response (00042)

Class 6: Thermoregulation

Hyperthermia (00007)

Hypothermia (00006)

Ineffective Thermoregulation (00008)

Class 2: Environmental Comfort

Class 3: Social Comfort

Readiness for Enhanced Comfort (00183)

Nausea (00134)

Acute Pain (00132)

Chronic Pain (00133)

Social Isolation (00053)

Class 2: Development

Risk for Delayed Development (00112)

Disturbed Sensory Perception (Specify: Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory) (00122); retired 2012-2014

Before each disorder name, ICD-9-CM codes are provided, followed by ICD-10-CM codes in parentheses. Blank lines indicate that either the ICD-9-CM or the ICD-10-CM code is not applicable. For some disorders, the code can be indicated only according to the subtype or specifier.

ICD-9-CM codes are to be used for coding purposes in the United States through September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014.

Following chapter titles and disorder names, page numbers for the corresponding text or criteria are included in parentheses.

Note for all mental disorders due to another medical condition: Indicate the name of the other medical condition in the name of the mental disorder due to [the medical condition]. The code and name for the other medical condition should be listed first immediately before the mental disorder due to the medical condition.