1. What is the primary purpose of a Comprehensive Psychiatric Evaluation Note? a) To prescribe medication b) To document billing codes c) To assess and plan mental health treatment d) To record physical exam findings Answer: c) To assess and plan mental health treatment Explanation: The note provides a full picture of the patient’s psychiatric status and guides treatment.
2. Which section includes the patient’s own words about their symptoms? a) Mental Status Exam b) Chief Complaint c) Diagnostic Impression d) Risk Assessment Answer: b) Chief Complaint Explanation: The chief complaint captures the patient’s reason for seeking help.
3. What does MSE stand for? a) Medical Screening Evaluation b) Mental Status Examination c) Medication Safety Evaluation d) Mood Stability Estimate Answer: b) Mental Status Examination Explanation: MSE assesses the patient’s current mental functioning.
4. Which domain of the MSE evaluates emotional expression? a) Mood b) Affect c) Thought Process d) Cognition Answer: b) Affect Explanation: Affect refers to the observable emotional state.
5. What is included in the social history? a) Blood pressure readings b) Medication allergies c) Living situation and relationships d) Hallucinations Answer: c) Living situation and relationships Explanation: Social history covers environmental and interpersonal factors.
6. Which tool is used to classify psychiatric diagnoses? a) ICD-10 b) DSM-5 c) MSE d) HIPAA Answer: b) DSM-5 Explanation: DSM-5 provides criteria for mental health diagnoses.
7. What does the formulation section summarize? a) Medication side effects b) Biopsychosocial contributors to illness c) Billing information d) Legal history Answer: b) Biopsychosocial contributors to illness Explanation: Formulation explains how various factors influence the condition.
8. Which of the following is part of the risk assessment? a) Sleep patterns b) Suicidal ideation c) Appetite changes d) Speech rate Answer: b) Suicidal ideation Explanation: Risk assessment evaluates potential harm to self or others.
9. What is a common psychotherapy used in treatment plans? a) Chemotherapy b) CBT c) MRI d) ECT Answer: b) CBT Explanation: Cognitive Behavioral Therapy is widely used for mental health treatment.
10. What does HIPAA protect? a) Medication dosages b) Patient confidentiality c) Insurance premiums d) Diagnostic codes Answer: b) Patient confidentiality Explanation: HIPAA ensures privacy of health information.
11. Which section would include hallucinations? a) Thought Process b) Perception c) Cognition d) Judgment Answer: b) Perception Explanation: Perception covers sensory experiences like hallucinations.
12. What is the role of the diagnostic impression? a) To list medications b) To summarize the MSE c) To provide a working diagnosis d) To record lab results Answer: c) To provide a working diagnosis Explanation: It identifies the mental health condition based on evaluation.
13. What is a PRN medication? a) Taken daily b) Taken as needed c) Taken before meals d) Taken at bedtime Answer: b) Taken as needed Explanation: PRN means “pro re nata,” or as needed.
14. Which professional typically writes a psychiatric evaluation note? a) Dentist b) Psychiatrist or mental health clinician c) Physical therapist d) Radiologist Answer: b) Psychiatrist or mental health clinician Explanation: Mental health professionals conduct psychiatric evaluations.
15. What should be avoided in documentation? a) Objective language b) Patient quotes c) Jargon and vague terms d) Confidentiality statements Answer: c) Jargon and vague terms Explanation: Clear and precise language improves clinical communication.