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