Mental Health Assessment

The Assessment Process

Assessment as a Process Deliberate and systematic collection and interpretation of biopsychosocial information or data to determine current and past health, functional status and human responses to mental health problems, both actual and potential

Assessment • Initial Assessment – Comprehensive – all data – Screening – Recognize symptoms, risk factors or emotional difficulties.

• Ongoing Assessment – Monitor the progress and outcomes of the interventions. – Focused

Techniques of Data Collection • Patient observations • Interviews - patient and family (Text Box 11.2)

• Physical examination • Records and diagnostic reports • Collaboration with colleagues

Biopsychosocial Assessment – Laboratory Results • CBC • Electrolytes – Na+, K+

• Renal Function Tests – BUN, Creatinine

• Serum enzymes – Amylase, SGOT, CPK

• Thyroid Function – T3, T4, TSH

Assessment: Biologic Domain • Physical Functions – – – – – – –

Elimination Activity and exercise Sleep Appetite and nutrition Hydration Sexuality Self-care

• Pharmacologic – Current and past medications – Over-the-counter, vitamins, herbal supplements

Assessment: Psychological Domain • Responses to mental health problems or consequences • Mental status examination – – – – – – – – – –

General observation, appearance, psychomotor activity, attitude Orientation Mood, affect, emotions Speech Thought processes Cognition and intellectual performance Attention and concentration Abstract reasoning and comprehension Memory: recall, short-term, long-term (remote) Judgment and insight

MMSE • • • • •

Orientation Registration Attention and Calculation Recall Language

Assessment: Psychological Domain • Behavior • Self-concept – Body image – Self-esteem – Personal identity

• Stress and Coping Patterns • Risk Assessment – Suicidal ideation – Assaultive or homicidal ideation

Suicide Assessment • • • • • •

Have you ever tried to harm or kill yourself? Do you have thoughts of suicide at this time? If yes, do you have a plan? If yes, can you tell me the details? Do you have the means? Have you made preparations? Giving things away, etc. • Has a significant episode made you feel this way?

Assaultive or Homicidal Assessment • • • • •

Do you intend to harm someone? If yes, who? Do you have a plan? If yes, what are the details of the plan? Do you have the means to carry out the plan? Where is the weapon?

Social Assessment • Functional Status • Social Systems – Family assessment – Cultural assessment – Community support and resources

• • • • •

Spiritual Assessment Occupational Status Economic Status Legal Status Quality of Life