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RISK TO SELF TO OTHERS DEFINITION EXAMPLE DEFINITION EXAMPLE Intended Effect of the behaviour is deliberate and volitional Patient jumps in front of a subway train intending to be killed Material harm to others is deliberate and volitional Patient stabs family doctor owing to delusional belief that the doctor implanted a monitoring device in the patient’s body Unintended Effect of patient behaviour on himself or herself is neither foreseen nor desired Delusional patient stops drinking fluids owing to belief that she is being poisoned Material harm to others from the patient’s behaviour is neither foreseen nor desired An intoxicated parent fails to notice his toddler enter the backyard swimming pool Iatrogenic Adverse consequences of medical intervention are neither foreseen nor desired An elderly patient prescribed a benzodiazepine falls on her way to the bathroom during the night, suffering a subdural hematoma Adverse consequences of medical intervention are neither foreseen nor desired Patient who started taking quetiapine strikes a pedestrian while driving the next morning FUNCTION OBSERVED REPORTED SUSPECTED DEFINITION EXAMPLE DEFINITION EXAMPLE DEFINITION EXAMPLE Personal care Basic ADLs witnessed by the physician. Walking, maintaining continence, and managing money are the 3 that could be observed or directly assessed After the patient leaves the examination room, the chair is wet and foul smelling ADLs and IADLs communicated by the patient or others The patient’s husband reports that he assists her to dress Physician infers impaired personal care on the basis of indirect or absent information, or manner of response The patient is poorly groomed and is malodorous Dependents Physician witnesses neglect or mistreatment of dependents During the assessment the patient shows no response to her infant’s cries Impaired ability to care for dependents is communicated by patient or others The patient reports he has forgotten to pick up his son from school several times Physician infers an impaired ability to care for dependents based on observed or reported phenomena The patient states she begins drinking alcohol at 4 pm and by 8 pm has difficulty “controlling” the children Licences Witnessed behaviour in direct violation of the conditions of licensure Patient arrives at the clinic intoxicated, having driven there Violation of licensure or lack of fitness communicated to physician by patient or others Patient reports he has made numerous errors in the operation of his crane owing to distractibility Inferred from indirect evidence Patient’s level of arousal and attentiveness is grossly impaired on mental status examination and the physician suspects impairment in patient’s role as a bus driver Relationships Witnessed impaired or inappropriate social interactions with providers or others Patient comes to the visit with his sister. He yells at and threatens her when she begins to describe the family’s concerns Impaired or inappropriate social interactions communicated by patient or others Staff report that the patient was sitting very closely to and staring intensely at another patient in the waiting area Impaired or inappropriate social interactions inferred from indirect evidence. Predominantly obtained from narratives or signs and symptoms The patient reveals that she has no friends, people hate her, and she feels lonely, but the physician knows the patient to previously have been very social Work Demonstrated impaired attendance, performance, or behaviour An occupational health physician is given a worker’s performance record Impaired attendance, performance, or behaviour reported by patient or others The patient gives the physician a form from work requiring medical support for 9 sick days in the past 2 mo Impaired attendance, performance, or behaviour inferred from indirect evidence The patient reports co-workers are lazy and rowdy and he is getting tired of telling them to be quiet Education Demonstrated impaired attendance, performance, or behaviour A university physician is given a student’s transcript Impaired attendance, performance, or behaviour reported by patient or others The patient reports that he has not attended class for 2 wk Impaired attendance, performance, or behaviour inferred from indirect evidence A patient asks you for a letter to extend the due date for an assignment ADLs—activities of daily living, IADLs—instrumental ADLs.
SYMPTOMS OBSERVED REPORTED SUSPECTED DEFINITION EXAMPLE DEFINITION EXAMPLE DEFINITION EXAMPLE Cognitive Directly observed or assessed phenomena pertaining to the mental processes of knowledge, perception, memory, judgment, and reasoning The patient frequently asks the physician to repeat questions and is unable to decide when to book the next visit Experience of mental processes is described by the patient or signs relating to mental processes are described by others The patient describes concern about forgetfulness, feeling anxious, and an inability to make decisions. The patient’s mother describes observations that reflect illogical thinking Impairment in cognitive processes is inferred on the basis of described behaviour, events, or experiences The patient describes answering the telephone while her toddler is in the bathtub and only recalling that she has done so when alerted by a cry from the bathroom Emotional Patient displays behavioural manifestations of feelings and mood states observed by the physician* The patient is smiling and laughing throughout the office visit A patient’s specific description of feelings or mood, or related somatic or physiologic experience The patient describes that she feels very content and happy and no longer has any worries Inferred feelings or mood states from the patient’s statements or behaviour The patient is not spontaneous in speech, speaks softly, and believes her current situation has no solution Sensory A patient’s sensory experiences cannot be observed. Beyond the standard senses of vision, hearing, taste, smell, touch, temperature, and pain, keep in mind other senses such as proprioception, kinesthesia, acceleration, velocity, orientation to gravity, etc. One can observe consequences of the sensory experience (eg, blindness, deafness) through behaviour, but these will often be inferred The patient knocks over items and bumps into furniture as she walks into the room A patient’s or other’s report of sensory experiences or explicit description of experiences that are confirmed to be sensations by the physician The patient reports hearing voices Experiences that are described or alluded to by the patient or observations by others, or direct observations by the physician that might be interpreted as sensory phenomena. Treat suspicion as a hypothesis to be tested over time Patient frequently stops speaking mid-sentence and looks around the room. Physician infers the patient is hearing voices Behavioural Observed patient actions The patient’s speech is extremely loud and pressured Patient or others report behaviour The patient reports she has been staying up all night and spending excessive amounts of money shopping Suspected behaviour based on information received by the physician Patient denies drinking but has a high MCV and recently had a car accident MCV—mean corpuscular volume.
↵* Emotions are inferred.
