Focused Exam: PTSD (Part 3 of 4) C487 Psych/Mental Health Clinical - Aug 2018, C487

Focused Exam: PTSD (Part 3 of 4) C487 Psych/Mental Health Clinical - Aug 2018, C487 Return to Assignment Reflections Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor insight into your learning process. This reflection activity will help you think more deeply about your performance in the assignment. Use your documentation as you respond to the prompts at the bottom of the page. Documentation Review Mental Status Note Student Response Model Documentation Appearance clean, well kept normal for age Ms. Diaz is a 48-year-old Cuban American woman of average height. She appears overweight. Eye contact is direct. Her expression is tense and posture rigid. Her clothing is appropriate to her age and occasion. She appears well groomed. Attitude cooperative, engaged, open, relaxed Ms. Diaz is cooperative, but is anxious and appears guarded when asked about her social history. Motor Activity lack of eye contact, flat facial expression, no involuntary movements Ms. Diaz's motor activity appears agitated. She has a clenched jaw and clenched fists. She has a steady gait and continuous steps.