Psychiatric/Mental Health Assessment

Psychiatric/Mental Health Assessment

General Safety Guidelines
■ Safety:Your safety ALWAYS comes first!
■ Awareness:Watch for nonverbal indicators of aggression or violence; clinched fists, pacing, raised tone of voice, increased respirations, profanity, verbal threats, weapons, wide-eyed stare.
■ Exit: Always position yourself between the Pt and an exit. Never allow a Pt to block your means of escape.
■ Be Assertive: Make your boundaries known, set limits, and stick to them. Avoid arguing or bargaining with Pts.

Component	Document: assessment, interventions, outcomes
Appearance	Grooming, hygiene, posture, eye contact, correlation between appearance and developmental stage and age.
Motor Activity	Tremors, tics, mannerisms, gestures, gait, hyperactivity, restlessness, agitation, echopraxia, rigidity, aggressiveness.
Speech Pattern	phasia, volume, impairments, stutter.
General Attitude	Cooperative, uncooperative, friendly, hostile, defensive, guarded, apathetic.
Mood	Depressed, sad, anxious, fearful, labile, irritable, elated, euphoric, guilty, despairing.
Affect	Congruent with mood, flat, inappropriate.
Thought Process	Form of thought: tangentiality, word salads, neologisms, echolalia, attention span. Content of thought: delusional, suicidal, homicidal, obsessive, paranoid, suspicious, religiosity, phobic, magical.
Perceptual Disturbances	Hallucinations (auditory, visual, tactile, olfactory, gustatory), illusions (depersonalization, derealization).
Sensory/Cognitive	Alertness/orientation/memory/abstract.
Impulse Control	Aggression, fear, guilt, affection, sexual.
Judgment/Insight	Decision making, problem-solving, coping.