Documentation Assignment David Carter.docx - Mental Health...

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Mental Health Case: David Carter, Part 1 Documentation Assignments 1. Document findings associated with your screening of Mr. Carter using the AIMS scale.drawn. The Patient Mr. Carter is disheveled and withdrawn. He is appropriately dressed; however, his clothes are dirty. He is sitting in a slouched position; his eyes are downcast with a few brief moments of eye contact. He is talking to himself about spies and being poisoned. The patient will engage with you, but is very apprehensive about it. His speech is tangential with some some noted neologisms. He has difficulty following the conversation due to auditory hallucinations. Orientation and cognitive function are impaired . The patient is restless , although his movements are purposeful and coordinated. There are no evidence of tics, tremors, or unusual movements. He no longer finds pleasure in activities he once enjoyed. 2. Document Mr. Carter’s performance of activities of daily living and his intake and output for the day.

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