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> mental health needs patient assessment
mental health needs patient assessment
Patient Identification and Demographics
Gather patient’s name, age, gender, and contact information.
Record emergency contact details.
Note the date of assessment.
Medical History
Document any previous mental health diagnoses.
Record current medications and dosages.
Note any history of hospitalizations related to mental health.
Assess for any chronic medical conditions.
Current Mental Health Status
Inquire about current symptoms and their duration.
Assess the severity of symptoms using appropriate scales.
Evaluate suicidal thoughts or self-harming behaviors.
Explore any recent changes in mood or behavior.
Social History
Review living situation and support system.
Assess employment status and job satisfaction.
Document any history of substance use or abuse.
Explore relationships with family and friends.
Functional Assessment
Evaluate daily functioning (e.g., self-care, work, social activities).
Assess coping strategies and skills.
Identify any barriers to functioning.
Risk Assessment
Evaluate risk of harm to self or others.
Assess risk factors for suicidality or self-injury.
Identify any protective factors.
Strengths and Resources
Identify personal strengths and coping mechanisms.
Explore available support systems in the community.
Document any previous successful interventions or treatments.
Treatment Goals and Planning
Discuss patient’s goals for treatment.
Collaboratively develop a treatment plan.
Outline potential interventions and resources.
Schedule follow-up appointments as needed.
Documentation and Follow-Up
Document all findings in the patient’s record.
Ensure confidentiality and compliance with regulations.
Set reminders for follow-up assessments and check-ins.
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