ASSESSEMENT OF MENTAL HEALTH STATUS OF A PSYCHIATRIC PATIENT

REQUIREMENTS #

1. Table
2. Chair
3. Pen and paper
4. Patient’s folder (Electronic/ Manual)

STEPS #

1. Welcome patient and offer a comfortable seat
2. Use simple clear language the patient understands
3. Establish rapport (refer procedure) and explain the reason for the interaction
4. Ensure privacy and assure patient of confidentiality
5. Obtain information from the following areas:
   1. Appearance – grooming, facial expression, deformity, etc.
   2. General Attitude – cooperative, hostile, overly anxious etc.
   3. Motor Activity – hyperactivity, retardation, gait, etc.
   4. Thought Process
      1. Thought form – word salad, thought block, flight of ideas etc.
      2. Thought content – delusions, suicidal ideation, magical ideation, etc.
   5. Speech – rate, coherent, stuttering, etc.
   6. Emotions
      1. Mood – irritable, euphoria, depression, etc.
      2. Affect – congruence, blunt, flat, etc.
   7. Perceptual disturbances – hallucinations, illusion, depersonalization, etc.
   8. Sensorium and Cognitive ability – orientation, memory, consciousness, etc.
   9. Impulse control – aggression, affection, sexual feeling, etc.
   10. Judgment and Insight – arithmetic ability, awareness of illness, decision making, etc.
6. Express appreciation to patient
7. Document assessment findings in the nurse’s note/ patient folder