Charting is the process of recording pertinent medical information in a patient's chart. Actual charts are not required for this process, however, some medical practitioners do choose to use them to help keep information organized. If you need to record information about your patient's bipolar symptoms, use the diagnostic criteria as a guide to ensure that you include all necessary information.
Step 1
Create a section called "Mood Symptoms." Criteria A for bipolar disorder requires that a patient have experienced an abnormally elevated, expansive or irritable mood for at least one week. Ask your patient to describe any changes in mood and the duration of these changes. Record her response as well as your assessment of these changes.
Step 2
Create a section called "Behavioral Symptoms." Criteria B requires that the patient have exhibited three or more of the following symptoms related to mania during the period in question: inflated sense of self or grandiosity, decreased need for sleep (i.e. sleeping only two to three hours each night yet feeling rested), being extremely talkative or feeling undue pressure to continue talking, racing thoughts or inability to capture thoughts, distractability, drastic increase in goal-directed activity (i.e. taking on an unreasonable amount of unnecessary work at work or school or even sexual activity) or excessive involvement in pleasurable activities (i.e. reckless shopping sprees, promiscuity or spending money irresponsibly). If the mood was primarily irritable, the required number of symptoms is four. Ask your patient to describe her typical behavior for the period in question and record all examples.
Step 3
Create a section called "Diagnostic Variations." Criteria C requires assessment to determine if the behavior is strictly manic and not a part of a mixed episode (manic and major depressive symptoms). In order to rule out other disease variations, review the examples recorded in Step 2 to determine if there are behaviors that indicate a mixed episode.
Step 4
Create a section called "Functioning." Criteria D requires that the symptoms or changes in behavior have caused significant, evident impairment in general functioning in a variety of areas (home, school, work, etc.). Ask your patient how she has been managing the primary areas of her life at home, work or school. Record her responses and assess for any levels of impairment.
Step 5
Create a section called "Potential Causes." Criteria E requires that an assessment that substance use or the presence of medications to treat another illness is not the cause. Ask your patient about her use of alcohol and drugs as well as any illnesses. Record that information and consider whether any of these instances is the potential cause of her symptoms.
Tips and Warnings
- A formal diagnosis of any mental illness or disorder must be made by a licensed professional such as a counselor, therapist, psychologist or psychiatrist.
References
- National Institute of Mental Health: Manic Depression (Bipolar Disorder)
- American Psychiatric Association, Diagnostic and Statistical Manual, Fourth Edition
