A mental health assessment gives a detailed look at all of the factors that contribute to the patient's health history.The assessment form should have a lot of information entered.The assessment takes into account the patient's mental health history, medical history and social history.
Step 1: The patient should give background information.
Background information can be used to establish context for your assessment.The interview will be fruitful if the patient is put at ease.If you want the patient to be comfortable in providing the information you need for the assessment, make small talk and keep eye contact.The patient's age, gender, and ethnicity will be some of the basic information.Some information will tell us more about the patient.
Step 2: You can record the patient's medical history.
The assessment has all the boxes checked.Affirm wherever additional description is required.Current drugs include prescription and over-the-counter drugs.The patient has a substance abuse history.List all the drugs the client is taking.Sometimes physical conditions can mimic mental illnesses.If a patient has asthma and anxiety, the asthma might be provoking the anxiety.
Step 3: You should record the patient's mental health history.
The patient should be encouraged to use their own words.They can describe social circumstances and emotional reactions that might not be revealed with the story they provide.Asking questions about a patient's mental health history may seem personal to them.They will feel comfortable discussing this with you if you give them a calm, open demeanor.Indicate the dates of diagnoses and responses to treatments.The presenting problem, symptoms, previous treatments and providers should be mentioned.
Step 4: You can record cultural factors on the paper.
Ethnicity, immigration, language, religion, sexual orientation should be included in this portion of the assessment.The patient's behavior can be impacted by cultural factors.
Step 5: A narrative summary is a summary of your findings.
This is a written interpretation of the information collected and how it contributes to the patient's presenting problem.Every component of the patient's history is significant and will have an impact on the treatment.
Step 6: The patient has a mental health problem.
Current symptoms and behavior should be included.A description of the problem's start, duration and intensity is required.Look for non-verbal clues from the client such as being nervous or unable to make eye contact.Observe and note the patient's behavior and appearance.
Step 7: The patient's psychosocial history should be assessed.
Family history and social relationships should be included.The patient has a family history.The patient's medical history and status should be indicated.Jim has been HIV positive for three years and has a T-cell count within the normal range.There are many factors that contribute to the patient's support system, education and employment.The patient has strengths and weaknesses.Is the patient willing to work on the problems?Will the patient have a support system in place?Does the patient have financial problems that might prevent them from completing treatment?
Step 8: Determine risk factors for the patient.
The assessment of the risk factors is determined by the information gathered during the interview.Some of the risk factors are suicidal, homicidal, homelessness, trauma, neglect, abuse, domestic violence.
Step 9: Check all the boxes that apply on the Mental Status Exam.
Thought content will include delusions, affect, mood and orientation.You will have to give your comments and descriptions."Appropriate," "Inappropriate," and follow with a description of the behavior are examples.
Step 10: The Criteria for Complete the Medical Necessity.
You need to describe the patient's impairments in this section of the assessment.The categories include health, daily activities, social relationships and living arrangements.Detailed descriptions will be required if selected.
Step 11: Amultidimensional approach is used to diagnose the patient.
The Diagnostic and Statistical Manual of Mental Disorders can be used to categorize mental disorders.The format is changing.The "principal diagnosis" should be followed by the phrase "reason for visit" in the new format.The old method assesses five dimensions.For each axis, include a diagnosis for the primary presenting problem.The Global assessment of functioning is a numerical rating on a scale of 0 to 100.The patient is high functioning and easily managing the stressors in his or her life if he or she has a GAF score of 91-100.A score of 1-10 indicates that the patient is a danger to himself or others.
Step 12: It's a good idea to recommend treatment for the patient.
Recommendations should be based on your assessment and narrative summary.Specific time frames for completion are what your treatment goals must be.What the patient sees as the ideal outcome from treatment is part of an assessment.Some patients want only therapy, others want medicine, and still others prefer a combination of the two.You have to try to get the patient to where they want to be in a way that's still clinically appropriate.There is a list of treatment goals.Reducing risk factors and decreasing functional impairment are examples.Indicate the plans for prevention with patient participation.Anger management, parent training, and problem solving are examples.
Step 13: The patient's understanding of the treatment should be documented.
The patient's understanding of the course of treatment and its goals should be stated in the conclusion of your assessment.The patient is aware of the decided course of treatment and willing to work with it.Patients report better outcomes when they agree with their doctors on the course of treatment.Negotiating between patient and mental health care provider will ensure effective interventions.