Psychiatric and Mental Status MT Words and Phrases For Medical Transcriptionists

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.

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
antisocial behavior
antisocial traits (personality disorder with antisocial traits)

apathy, indifference
appears detached and aloof

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
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
demonstrated good recall
depressive disorder, not otherwise specified (NOS = not otherwise specified)
difficulty establishing and switching cognitive sets
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
grip strength
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
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 ideations
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
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
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
schizoaffective disorder, bipolar type
schizophrenia, paranoid subtype
schizophreniform disorder
sense of hopelessness
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
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