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