Resident is a married White 84-year old woman admitted to My Better Nursing Home on 1/1/11 with Dx of Supercalifragilisticexpialidocious. ∅ psychotropic meds. Resident was born in NY, has a PhD in psychology, and worked in nursing homes until her retirement. Involved family. Chart reviewed and resident discussed with staff.
Resident was alert, Ox3, and cooperative with the interview. She reported some anxiety related to future events, and acknowledged occasional sleep disturbance. Some irritability noted. Prior MH tx; stated it was part of her training. No HSI. No ETOH. Speech logical and goal-directed; normal rate and tone. Fund of information good. No A/V hallucinations. ADLs good. Sense of humor intact.