Mental Health Assessment Form FAQs
1) What’s included in a mental health assessment?
When a professional medical provider conducts a mental health assessment, they help patients determine whether they have a mental health problem and decide on the best treatment plan.
Since mental health issues can be associated with physical ailments, a doctor will attempt to rule out any physical problems, so a mental health exam may include a physical exam and lab tests.
The doctor will also likely ask the individual about their mental health history, personal history, and family history. The patient should be prepared for questions regarding their day-to-day life and for basic cognitive tests that help the doctor assess their ability to think clearly.
2) How is a mental health assessment documented?
Assessing mental health is a challenge since these problems can have many different sources. It’s important to collect accurate and detailed information, including the duration of symptoms, as they’re critical to the diagnosis. Documenting the information promptly can help healthcare providers ensure they don’t forget anything, and doing so digitally ensures that the information is legible.
The documentation should start with an overview of the patient’s situation, like their health history, personal history, and family history. Following that should be a description of the current mental health problem they’re dealing with and their current state.
Below are several types of information typically documented during a mental health assessment:
- Appearance. How would you describe the patient’s appearance? This description should include facial expressions, grooming, dress, etc.
- Orientation. Is the patient aware of where they are, what time it is, and what’s going on?
- Speech patterns. How would you describe their communication? Is their speech slow or slurred? Do they seem stressed or calm?
- Mood. What is the individual’s current mood — normal, depressed, stressed, etc.?
- Risk. Are they a risk to themselves, or are they in an environment where someone or something presents a danger to them? Include a description of what risk factors are affecting the individual.
- Judgment and thought processes. Is the patient able to assess the consequences of their actions and make rational decisions? Do their statements about their situation and surroundings indicate that they’re grounded in reality?
- Intellectual capacity. Do their intellectual and memory capacities seem normal or impaired? How do they perform on basic cognitive tests?
3) Are there other terms for a mental health assessment?
A mental health assessment can also be called a psychiatric assessment or psychological screening as well as mental status testing or neurocognitive testing. The purpose is to test an individual’s current mental state, assess the severity of their mental health issue, and determine a treatment plan.
4) What are the different methods for mental health assessments?
- Observation. Observing an individual firsthand is essential to learning about their condition. They may exhibit cues that differ from what they say. This assessment includes observing appearance, speech, orientation, and other behaviors.
- Psychiatric interviews. Interviews are a great opportunity to build rapport with the individual and help them open up. You may uncover factors contributing to their current mental health situation by using open-ended questions that allow them to express themselves.
- Family interviews. When dealing with minors or individuals with severe medical conditions, the caregiver’s help may be necessary to understand the situation. The caregiver can provide a well-rounded view of the patient’s situation and contributing factors. Keep in mind that following HIPAA guidelines are critical when you’re working with family members or caregivers.
- Screening lists. Checklists can help identify and classify a patient’s symptoms. These lists may not factor in underlying physical health conditions, patient history, etc., so you should use these in conjunction with other assessment methods to ensure patients receive a thorough evaluation.
- Rating scales. Rating scales help turn complex emotions into simple numerical calculations. A rating scale helps quickly analyze ailment probability, severity, and other factors. Some common assessments include the Minnesota Multiphasic Personality Inventory (MMPI-2), Beck Depression Inventory, and Beck Anxiety Inventory.
- Specialized questionnaires. Questionnaires allow a physician to dive deeper into specific disorders and ask patients targeted questions that aid in the assessment. Collecting disorder-specific data is a key pre-diagnosis step that helps professionals proceed more accurately.
5) Who should perform mental health assessments?
Only qualified professionals should perform mental health assessments. Family doctors, psychologists, and psychiatrists have the medical training needed to distinguish between different conditions and recognize when an individual may need to see a different type of specialist. Diagnosis by an unqualified individual can be dangerous, as it could involve misdiagnosis and the delay of care for serious conditions.
6) How often should a patient have a mental health assessment?
Determining how often to conduct a mental health assessment depends on the current health of an individual.
For example, someone who’s actively dealing with a mental health condition may require monthly or weekly care. However, a diagnostic assessment is recommended at least every three years for an adult who receives mental health services.
The best practice is to encourage individuals to consult with their current medical provider regarding the frequency of their mental health assessments.
User Reviews
"We recently started using this template for mental health assessments at our clinic. It was easy to customize to include specific conditions we needed to address. Worked out great for us!"
Malinda D. Farmer - 07/30/2024
