Medical Transcription Phrases, Words, And Helpful Hints


PSYCHIATRIC OR MENTAL STATUS PHRASES & WORDS FOR MTs: 

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Explanation of Axis I to V:

 

Axis I:     Clinical disorders, syndromes and/or other areas of concern

 

Axis II:   Personality disorders and mental retardation

 

Axis III: Medical conditions (which may impact emotions)

 

Axis IV:  Psychosocial stressors (death, divorce, loss of job, etc.)

 

Axis V:    Global assessment of functioning.

 

COMMON PHRASES AND WORDS:

 

3-step command

 


able to spell "world" backwards

 


able to provide a correct year, month, date, day of the week, correct state, city

 


able to recite alphabet correctly in a timely manner and count backwards

 


able to maintain attention on the task at hand

 


able to name 2 out of 2 common objects and 5 out of 5 body parts

 


able to comprehend presented questions and commands correctly

 

ankle jerks

 

able to name objects, repeat phrases

 

able to process information

 

able to recall 3 out of 3 words

 

able to spell the word "world" backwards

 

adjustment disorder with depressed mood

 

adjustment disorder with depressed mood, in full remission

 

adjustment disorder with diminished mood

 

adjustment disorder with mixed anxiety and depression

 

affect was appropriate to content and normal in range

 

affect was blunted / affect was full range

 

affect was tearful / affect was euthymic

 

alcohol-induced psychotic disorder with hallucinations

 


all three spheres / all 3 spheres

 

anhedonia

 

antisocial behavior

 

antisocial traits (personality disorder with antisocial traits)

 


apathy, indifference

 

aphasia

 

appears detached and aloof

 


ataxia

 

attention and concentration

 

attention deficit hyperactivity disorder, combined type

 


auditory or visual hallucinations

 

awareness of current events

 

bipolar affective disorder, type II

 

borderline personality disorder with obsessive-compulsive features

 

bradykinesia

 

bradyphrenia, bradykinesia, rigidity, psychomotor slowing

 

Broca's aphasia

 

buccofacial and ideomotor apraxia

 

capacity for self-introspection

 

chronic schizophrenia, paranoid type

 

chronological order

 

cluster B traits

 

cocaine-induced mood disorder

 


cogwheeling, rigidity, spasticity

 

command hallucinations

 

constricted affect

 

conversion disorder

 


coordination and gait are intact

 

deep tendon reflexes are brisk and equal

 

delayed grief

 


delusional

 

demonstrated good recall

 

depressive disorder, not otherwise specified (NOS = not otherwise specified)

 


despondent

 

difficulty establishing and switching cognitive sets

 

disheveled

 

dysarthria

 

dysgraphia

 

dyskinetic movement

 

dysnomia, jargon or paraphasic errors

 

dysphoric mood

 

dysthymic disorder

 


emotional dyscontrol, lability, over-excited behavior and irritability 

 

expressive and receptive language

 

expressive aphasia

 

flight of ideas

 

Folstein Mini Mental status Exam

 

formal thought disorder

 

frontal release signs such as sucking, snout reflex, grasp, palmomental reflex, nuchocephalic and self-grasping were not elicited on testing

 

fund of knowledge

 

fund of general knowledge

 

gait is narrow based or wide based

 

glabellar reflex

 

good vocabulary

 

grandiose and expansive

 

grandiose ideation

 

grandiosity

 

grip strength

 

groomed

 

hallucinatory disturbances

 

hygiene and grooming (are fair / good / poor, etc)

 

hypothetical judgment

 


ideas of reference

 

illusionary experience

 

immediate recall / short-term recall

 


impulse control

 

impulse control disorder, not otherwise specified

 

impulsive reasoning

 


impulsivity, disinhibition

 

incoherent

 

insight and judgment

 


intermittent explosive disorder

 


internally preoccupied

 

judgment and problem-solving abilities

 

knee jerks

 

knows the city and state

 

limited vocabulary

 


letter perception was intact

 

loosening of association or flight of ideas

 


maintains eye contact  / does not maintain eye contact

 

major depressive disorder

 

major depressive disorder, recurrent

 


memory abstractions

 

mental status is intact in all four spheres

 

mental status is intact in all four spheres

 

mood appears depressed

 

mood was labile

 

narcissistic and histrionic features

 

narcissistic personality disorder with antisocial traits

 


new learning and delayed recall

 

no field cut to gross confrontation

 

no field cut to gross confrontation

 

no strange or odd posturing or mannerism

 


noncommand hallucinations

 


nonpressured speech

 

normal tone, bulk and power in all extremities

 

Novel motor programming

 

object perception

 

opioid-induced anxiety disorder

 


oriented to time, place, and person

 

palate moves symmetrically

 

palate moves up in the midline

 

panic attack

 

panic disorder

 

panic disorder without agoraphobia

 


paranoid

 

paranoid ideations

 


paresthesias

 


passive death wishes

 

paucity of thought

 

perceptual abnormalities

 


persecutory delusions

 

persecutory ideas of reference

 


perseverations or stimulus bounded behavior

 

plantar reflexes are flexor bilaterally

 

plantar responses

 

poor historian

 

postictal confusion

 

posttraumatic stress disorder (PTSD)

 


postural tremor

 

poverty of content

 

poverty of speech

 

prodromal symptoms of schizophrenia

 

proverb interpretation is concrete

 

proverb interpretation is fair

 


psychomotor dysfunction

 

psychopathology

 

psychotic symptoms

 

psychotic disorder, not otherwise specified

 


pupils are _____ (2, 3, or 4) mm and reactive

 


rapport seemed adequate

 

rate, volume and prosody of speech

 


reaction time to questions

 


reality testing was intact

 


recent and remote memory

 


recognition of low-level words

 

redirectable

 

reduplicative paramnesia

 

remembered 0/3 objects after 5 minutes

 

remembered 1/3 objects after 5 minutes

 

remembered 2/3 objects after 5 minutes

 

remembered 3/3 objects after 5 minutes

 


response to internal stimuli

 


responses were linear

 

restraints

 

Romberg

 

schizoaffective disorder, bipolar type

 

schizophrenia, paranoid subtype

 

schizophreniform disorder

 


sense of hopelessness

 

sensorium

 

Sensory exam:  All modalities are intact

 


serial 3s

 


serial 7s

 

shoulder shrugs

 


social phobia

 

somatic conversion symptom

 


somatic delusions

 

speech was clear, coherent, and goal directed

 

speech was normal rate, tone, volume

 

speech was rambling


 


staring into space

 


stream of mental activity was logical, relevant, coherent

 

stressors

 

suicidal or homicidal ideation

 

suicidal or homicidal ideas


 


switching cognitive sets

 

tactile discrimination

 

tangential thoughts

 

thought process was goal directed

 


thought blocking

 

thoughts, plan or intent (eg - suicidal or homicidal thoughts, plan or intent)

 


tongue protrudes to the midline

 


trend of thought

 

trouble with word finding

 

unintelligible and illogical

 


unresolved grief

 

uses rationalization and denial to explain

 


verbally contract for safety

 

vision was notable for floaters

 

visual fields are full to threat

 

visual fields were full and tactile localization was intact

 

visual withdrawal

 

visuoconstruction and visuomotor integration

 

voluminous details

  

Wernicke's aphasia

 

word salad and loose associations

 


word substitution  

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