الرئيسية›المساعدة›السريري›Psychiatry Module — MSE, Safety Assessments & Psychometric Scores
🩺

Psychiatry Module — MSE, Safety Assessments & Psychometric Scores

Document mental state examinations, safety assessments, mood tracking, and psychometric testing.

4 دقائق

# Psychiatry Module


ClinIT's psychiatry module provides structured tools for outpatient mental health practice, including MSE, risk assessment, mood tracking, and psychometric scoring.


---


Mental State Examination (MSE)


In every psychiatry session, the MSE Panel opens alongside the session notes.


### MSE Fields


DomainOptions
AppearanceAppropriate / Dishevelled / Neglected / Other
BehaviourCooperative / Agitated / Restless / Aggressive / Withdrawn
SpeechNormal rate/volume / Pressured / Slow / Muted / Circumstantial
Mood (subjective)Patient's own words
Affect (objective)Euthymic / Elevated / Depressed / Blunted / Flat / Labile / Incongruent
Thought FormLinear / Tangential / Loose associations / Flight of ideas / Thought block
Thought ContentNormal / Obsessional / Paranoid / Delusions (type) / Suicidal ideation
PerceptionsNo abnormal / Auditory hallucinations / Visual / Other
CognitionOriented ×3 / Memory intact / Attention intact
InsightFull / Partial / None
JudgementIntact / Impaired

---


Safety Assessment


If suicidal ideation, self-harm, or risk to others is noted in the MSE:


  1. A Safety Assessment panel opens (or can be opened manually).
  2. Record:

- Suicidal ideation: passive / active ideation / plan / intent / means access

- Self-harm history and current risk

- Risk to others

- Protective factors (family support, future plans, treatment engagement)

- Risk level: LOW / MODERATE / HIGH / VERY HIGH

- Safety plan (who to call, what to do in crisis)

- Clinician's action (continue outpatient / increase frequency / refer for admission / emergency intervention)


> ⚠️ Safety assessments are locked once the session is completed and cannot be edited without an addendum.


---


Psychometric Scores


Record standardised psychiatric rating scales:


ScaleCondition
PHQ-9Depression screening
GAD-7Anxiety screening
MADRSDepression severity
PANSSPsychosis
YMRSMania
PCL-5PTSD
OCI-ROCD
CAGE / AUDITAlcohol use
DAST-10Drug use

  1. Patient chart → Psychometric Scores → + Score.
  2. Select scale, enter item responses or total score.
  3. Severity band is calculated automatically.
  4. Trend charts track response to treatment.

---


Mood Diary (Patient-Facing)


Patients can log their daily mood in the portal. Each entry records:

  • Mood score (1–10).
  • Sleep hours.
  • Energy level.
  • Significant events.

The doctor sees the mood diary in the patient chart as a time-series graph.


The AI Mood Trajectory Predictor generates a narrative from the mood diary data.


---


Psychiatric Diagnoses


Record formal diagnoses with ICD-10 codes:

  1. Patient chart → Diagnoses → + Add Diagnosis.
  2. Select ICD-10 code from searchable list.
  3. Set status: Current / In Remission / Historical.
  4. Date of diagnosis.

---


Medication Monitoring


For patients on psychotropic medications, the Medication Monitor tracks:

  • Current psychotropic medications and doses.
  • Side-effect checklist (EPS, metabolic, sexual, sedation).
  • Adherence (self-reported).
  • Dose change history.

---


Treatment Package


For patients enrolled in structured therapy programmes (e.g. 12 sessions of CBT):

  1. Patient chart → Therapy Packages → + Enrol.
  2. Set therapy type, session count, frequency.
  3. Each completed session is tracked against the package.

---


Brain Stimulation (TMS / ECT)


For clinics offering TMS or ECT:

  1. Patient chart → Brain Stimulation → + Session.
  2. Record: modality, session number, parameters, patient response, adverse events.

المزيد في السريري

← كل مقالات السريري