From: Analysis of risk factor domains in psychosis patient health records
Domain | Description | Example | Example Keywords |
---|---|---|---|
Appearance | Physical appearance, gestures, and mannerisms | “A well-appearing, clean young woman appearing her stated age, pleasant and cooperative. Eye contact was good." | Disheveled, clothing, groomed, wearing, clean |
Thought Content | Suicidal/homicidal ideation, obsessions, phobias, delusions, hallucinations | “No SI, No HI, No hallucinations, Ideas of reference, Paranoid delusions" | Obsession, delusion, grandiose, ideation, suicidal, paranoid |
Interpersonal | Family situation, friendships, and other social relationships | “Pt. overall appears to be functioning very well despite this conflict with a romantic interest of hers." | Boyfriend, relationship, peers, family, parents, social |
Mood | Feelings and overall disposition | “Pt. indicates that his mood is becoming more ‘depressed.’" | Anxious, calm, depressed, labile, confused, cooperative |
Occupation | School and/or employment | “Pt. followed through with decision to leave college at this point in time." | Boss, employed, job, school, class, homework, work |
Thought Process | Pace and coherence of thoughts. Includes linear, goal-directed, perseverative, tangential, and flight of ideas | “Disorganized (Difficult to communicate with patient.), Paucity of thought, Thought-blocking." | Linear, tangential, prosody, blocking, goal-directed, perseverant |
Substance | Drug and/or alcohol use | “Patient used marijuana once which he believes triggered the current episode." | Cocaine, marijuana, ETOH, addiction, narcotic |
Other | Any example that does not fall into any of the other seven domains | “Maintain mood stabilization, prevent future episodes of mania, improve self-monitoring skills." | – |