Some of the information will be basic, such as the patient’s age, gender, and ethnicity. Some information will more telling in terms of what it reveals about the patient.
Include current medications (prescription and over-the-counter). [2] X Research source Note the patient’s substance abuse history. List all psychiatric drugs the client is currently taking. Keep in mind that sometimes physical conditions can mimic psychiatric illnesses. For instance, if a patient has uncontrolled asthma as well as anxiety, the asthma might actually be provoking the anxiety. [3] X Research source Padam Bhatia, MD. Psychiatrist. Personal interview. 12 May 2020.
Keep in mind that asking questions about a patient’s mental health history may seem very personal to them. Try to give off a calm, open demeanor so they’ll feel comfortable discussing this with you. [5] X Research source Padam Bhatia, MD. Psychiatrist. Personal interview. 12 May 2020. Indicate previous assessments,dates of diagnoses, referrals and responses to treatments. [6] X Research source Include details that refer to the onset of the presenting problem, symptoms, previous treatments and providers.
Include a description of the onset of the presenting problem, its duration and intensity. [9] X Research source Look for non-verbal clues from the client such as an inability to make eye contact and nervousness. Observe and note the patient’s hygiene, cleanliness, choice of clothing, behavior, mood and physical abnormalities. [10] X Trustworthy Source PubMed Central Journal archive from the U. S. National Institutes of Health Go to source
Describe the patient’s family history and current relationships. [11] X Research source Indicate the patient’s medical history and current status. Example “Jim is HIV positive and has been for three years, with a T-cell count within the normal range. “[12] X Research source Address a wide-ranging list contributing factors from the patient’s support system to education and employment. [13] X Research source Note the patient’s strengths and weaknesses. Does the patient seem willing to work on the presenting problems? Will the patient work with a support system in place? Does the patient have medical issues or financial problems that might prevent them from completing treatment?[14] X Research source
Examples of risk factors: Suicidal, homicidal, homelessness, trauma, neglect, abuse, domestic violence.
Example: Behavior: “Appropriate,” “Inappropriate,” and follow with a description of the behavior. [15] X Research source
Axis I: Primary presenting problem (such as major depressive disorder or bipolar disorder). Axis II: Personality disorder (ex: borderline personality disorder) or intellectual disability Axis III: Medical problems (only MDs can diagnose these) Axis IV: Psychosocial and Environmental Problems Axis V: Global assessment of functioning (GAF) is a numerical rating on a scale of 0 - 100 of the client’s current functioning with the life stressors he or she presents with. A GAF score of 91-100 means the patient is high functioning and easily managing the stressors in his or her life. A GAF score of 1-10 indicates that the patient is a danger to himself and/or others.
Part of an assessment involves trying to determine what the patient sees as the ideal outcome from treatment. For instance, some patients might want to pursue only therapy, others might want only medicine, and still others might prefer a combination of the two. You have to try the get the patient to where they want to be in a way that’s still clinically appropriate. [18] X Research source Padam Bhatia, MD. Psychiatrist. Personal interview. 12 May 2020. Compile a list of treatment goals. Examples:reducing risk factors, decreasing functional impairment. [19] X Research source Indicate planned preventions with patient participation. Examples would be anger management, parent training, problem solving. [20] X Research source
Patients report better outcomes to their treatment when they’re in agreement with their practitioners about the course of treatment. [22] X Trustworthy Source PubMed Central Journal archive from the U. S. National Institutes of Health Go to source Ensure effective interventions by implementing a negotiations process between patient and mental health care provider. [23] X Trustworthy Source PubMed Central Journal archive from the U. S. National Institutes of Health Go to source
