Threat to Self or Others

If the patient reports any current or past suicidality, homicidality, or self-injurious behavior, this should be clearly noted on the initial treatment report since these impact treatment necessity. For any suicidality or homicidality, clearly denote whether the patient reports ideation, plan, intent, access to means, or a past attempt.

Mental Status Examination

The Mental Status Examination is one part of clinical assessment that provides descriptive information about a patient’s observable presentation. The therapist should assess the patient at intake and provide mental status information in the initial treatment report. Many insurance companies will provide a mental status checklist on their treatment request forms. If no form is provided, the therapist will instead provide a brief written description using the mental status categories (and their respective descriptors) outlined next:

  • • Appearance: well groomed, disheveled, bizarre, or inappropriate
  • • Attitude: cooperative, uncooperative, hostile, guarded, suspicious, or regressed
  • • Orientation: fully oriented or impaired orientation to person, place, time, or purpose
  • • Motor activity: calm, hyperactive, agitated, tremors, tics, or muscle spasms
  • • Attention: good, fair, easily distracted, or highly distractible
  • • Mood: normal, depressed, anxious, or elevated
  • • Affect: appropriate, labile, expansive, constricted, or blunted
  • • Speech: normal, slow, slurred, pressured, or rapid
  • • Thought process: intact, circumstantial, tangential, flight of ideas, or loose associations
  • • Hallucinations: none, auditory, visual, olfactory, or command
  • • Delusions: none, persecutory, grandiose, or religious
  • • Memory: intact or impairment in immediate, short-term, or long-term memory
  • • Insight: able or not able to recognize symptoms as mental illness
< Prev   CONTENTS   Source   Next >