Psychiatry Module

Structured mental state examination

The initial psychiatric assessment records a full MSE in structured fields:

APPEARANCE & BEHAVIOUR

• Appearance: well-kempt / dishevelled / bizarre
• Eye contact: good / reduced / avoidant / fixed stare
• Psychomotor: normal / retarded / agitated
• Rapport: good / guarded / difficult

SPEECH

• Rate: normal / pressured / slow / mute
• Volume: normal / loud / soft
• Rhythm: fluent / dysarthric / stuttering

MOOD & AFFECT

• Subjective mood (patient's own words)
• Objective affect: euthymic / anxious / depressed / elated / irritable / labile / blunted / flat
• Congruence: mood-congruent / mood-incongruent

THOUGHT FORM & CONTENT

• Thought form: linear / circumstantial / tangential / flight of ideas / loosening of associations / thought block / neologisms
• Thought content: preoccupations, overvalued ideas, obsessions, delusions (type and theme)
• Suicidal ideation: passive wish / active ideation / plan / intent / means
• Homicidal ideation

PERCEPTION

• Hallucinations: auditory / visual / tactile / olfactory / gustatory
• Pseudo-hallucinations, depersonalisation, derealisation

COGNITION

• Orientation (person, place, time)
• Attention and concentration (serial 7s or MMSE digit span)
• Memory (recent, remote)
• Abstraction

INSIGHT & JUDGEMENT

• Insight: full / partial / absent
• Judgement: intact / impaired

DSM-5 diagnostic formulation:

After MSE, a structured DSM-5 multi-axial formulation is recorded. ICD-11 codes are supported alongside DSM-5.

Medication safety — QTc, clozapine, lithium

Three high-risk medication monitoring protocols are built into the psychiatry module:

QTC MONITORING

When any antipsychotic is prescribed, Clinit displays the CredibleMeds QTc risk category:

• Known Risk (red): haloperidol, ziprasidone, thioridazine
• Conditional Risk (amber): quetiapine, risperidone, aripiprazole
• Possible Risk (yellow): clozapine, olanzapine

If the patient is already on another QTc-prolonging drug (any category), a warning appears suggesting baseline ECG before initiation. The last recorded QTc value and date are displayed on the medication card. If the value is >450ms (male) or >470ms (female), or more than 3 months old, an amber badge prompts the clinician.

CLOZAPINE MONITORING SCHEDULE

Initiating clozapine activates a mandatory monitoring programme:

Weeks 1–18: weekly FBC — ANC must be ≥2.0 × 10⁹/L (green zone)

ANC 1.5–2.0 = amber (caution, monitor)

ANC <1.5 = red (stop immediately)

Weeks 19–52: fortnightly FBC

After 1 year: monthly FBC

Each FBC result is entered in the Clozapine Monitor sub-record. The prescription locks automatically until the current week's FBC is recorded and within the green zone.

LITHIUM MONITORING SCHEDULE

Target serum level: 0.6–1.0 mmol/L (maintenance)

0.8–1.0 mmol/L (acute mania)

Toxic threshold: ≥1.2 mmol/L → alert; ≥1.5 mmol/L → urgent review banner

Monitoring schedule prompted by Clinit:

• Serum lithium: every 3–6 months (after stable dose)
• eGFR: every 6 months (lithium is nephrotoxic)
• TSH: every 6–12 months (lithium causes hypothyroidism in ~40%)
• Calcium: annually

All results are trended. Overdue checks appear as amber badges on the medication card.