Crafting an Effective Mental Health Assessment

A mental health assessment provides a comprehensive examination of the various factors contributing to the patient's mental health history. The details provided in the assessment form should be thorough and comprehensive, incorporating the patient's mental health...

• Basic info like age, gender, and ethnicity is crucial. Other details provide deeper insights into the patient.

• Include current medications (both prescription and over-the-counter).
• Describe any history of substance abuse.
• List all psychiatric medications the patient is currently taking.
• Remember, physical conditions can sometimes mimic psychiatric disorders. For example, uncontrolled asthma might trigger anxiety.

• Recognize that inquiring about a patient's mental health history can feel very personal. Maintain a calm and open demeanor to help them feel comfortable discussing this with you.
• Include information about previous assessments, dates of diagnoses, referrals, and responses to treatments.
• Provide details regarding the onset of the current issue, symptoms, past treatments, and healthcare providers involved.

• Include details about the onset, duration, and severity of the problem.
• Observe non-verbal cues such as avoidance of eye contact and signs of nervousness.
• Take note of the patient's hygiene, attire, behavior, mood, and any physical abnormalities.

Evaluate the patient's psychosocial background. This encompasses aspects such as birth, upbringing, familial history, and social connections.

• Discuss the patient's current family dynamics and interpersonal relationships.
• Provide details regarding the patient's medical background and current health status. For instance, 'Jim has been living with HIV for three years, maintaining a normal T-cell count.'
• Explore various contributing factors ranging from the patient's support network to their educational and occupational status.
• Note the patient's strengths and weaknesses. Are they receptive to addressing their issues? Do they have a support system in place? Are there any medical or financial barriers hindering their treatment?

Assess the patient's risk factors. Offer a comprehensive evaluation based on information gathered during the interview.

• Identify potential risk factors such as suicidal tendencies, homicidal thoughts, homelessness, trauma, neglect, abuse, or domestic violence.

Share Your Insights

Which risk factor do you find most alarming in a patient?

Conduct a thorough Mental Status Examination, checking all relevant indicators. This includes assessing thought patterns (obsessions, hallucinations, delusions), mood, affect, and orientation. Detailed commentary and descriptions are necessary.

• Example: Behavior - 'Appropriate' or 'Inappropriate,' followed by a description of observed behaviors.

Address the Medical Necessity Criteria comprehensively. This section of the assessment entails outlining the patient's limitations across various domains, including health, daily functioning, social interactions, and living arrangements. Detailed explanations are required for selected categories.

Utilize a comprehensive approach to diagnose the patient. The Diagnostic and Statistical Manual of Mental Disorders is a key tool for categorizing psychiatric diagnoses. However, there's a new format in use which starts with the 'principal diagnosis,' followed by specifying the condition as the 'principal diagnosis' or 'reason for visit.' While some insurance companies may still adhere to the previous method, which involves assessing five dimensions (Axis), it's essential to include a diagnosis for each axis:

• Axis I: Primary presenting issue (e.g., major depressive disorder or bipolar disorder).
• Axis II: Personality disorder (e.g., borderline personality disorder) or intellectual disability.
• Axis III: Medical conditions (only diagnosable by medical doctors).
• Axis IV: Psychosocial and Environmental Issues.
• Axis V: Global assessment of functioning (GAF) provides a numerical rating, ranging from 0 to 100, of the client's current functioning considering life stressors. A GAF score of 91-100 indicates high functionality and effective management of life stressors, while a score of 1-10 suggests the patient poses a risk to themselves and/or others.

Provide recommendations for the patient's treatment. Base your recommendations on the narrative summary and assessment findings. Ensure that your treatment goals are measurable and have specific timeframes for completion.

• Part of the assessment process involves identifying the patient's desired treatment outcomes. Some patients may prefer therapy only, medication only, or a combination of both, and it's crucial to align with the patient's preferences while maintaining clinical appropriateness.
• Compile a list of treatment objectives, such as reducing risk factors and minimizing functional impairment.
• Outline preventive measures with patient involvement, such as anger management techniques, parental guidance, and problem-solving strategies.

Share Your Insights

What factors do you consider most important when establishing treatment goals?

Conclude by documenting the patient's comprehension of the treatment plan. Your assessment should wrap up with a statement regarding the patient's understanding of the proposed treatment and its objectives. This segment of the assessment demonstrates the patient's awareness of the agreed-upon treatment plan and willingness to collaborate.

• Patients tend to experience better treatment outcomes when they're in agreement with their healthcare providers regarding the treatment plan.
• Ensure the efficacy of interventions by facilitating a negotiation process between the patient and mental health care provider.

• Encourage the patient to share their story by asking open-ended questions regarding their concerns and personal history. This approach allows for a more comprehensive understanding of their situation and thought processes.
• Suggest the practice of journaling to aid in identifying specific mental health symptoms, offering a valuable self-reflection tool.
• If communication barriers exist, explore alternative sources of information such as family members, caseworkers, or law enforcement, ensuring patient confidentiality is upheld unless information is voluntarily shared.