Note: You can make up (create) the patient
Comprehensive Assessment of a Child/Adolescent Assignment Rubric
Distinguished Proficient Needs Improvement
Consent for Assessment Obtained
(5 points) Submits signed informed consent document permitting the learning access to the client and permission to conduct the clinical interview
(5 points) N/A- Either the learner obtained and submitted the informed consent document, or they did not.
(0 points) Learner did not submit a signed informed consent document permitting the learner access to the client and permission to conduct the clinical interview.
(0 points)
Assessment of Strengths, Talents, Interests and environmental supports
(10 points) -Discusses with clarity how child/adolescent is viewed within the family.
-Describes child/adolescent interests from the perspective of primary caregiver(s) as well as child.
-Availability of support for child/adolescent across settings (home, school, community, etc.)
-Describes future aspirations of child/adolescent
-Measures of child/adolescent self-concept
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(10 points maximum) Addresses less than 5 of the following areas or fails to address them with pertinent negative or similar statement(s):
-Discusses with clarity how child/adolescent is viewed within the family.
-Describes child/adolescent interests from the perspective of primary caregiver(s) as well as child.
-Availability of support for child/adolescent across settings (home, school, community, etc.)
-Describes future aspirations of child/adolescent
-Measures of child/adolescent self-concept
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(8 points maximum) Addresses less than 4 of the following areas or fails to address them with pertinent negative or similar statement(s):
-Discusses with clarity how child/adolescent is viewed within the family.
-Describes child/adolescent interests from the perspective of primary caregiver(s) as well as child.
-Availability of support for child/adolescent across settings (home, school, community, etc.)
-Describes future aspirations of child/adolescent
-Measures of child/adolescent self-concept
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(4 points maximum)
Patterns of Family Interaction/ Problems/Issues/ Family Psychiatric History
(15 points) -Discusses with clarity how members of the family interact with one another.
-Includes information on any family interaction difficulties (e.g., sibling rivalries, defiance’s, hostility toward family members, etc.)
-Assessment of psychiatric issues in the family (assessment should extend back to at least maternal/paternal grandparents).
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(15 points) Addresses less than 3 of the following areas or fails to address them with pertinent negative or similar statement(s):
-Discusses with clarity how members of the family interact with one another.
-Includes information on any family interaction difficulties (e.g., sibling rivalries, defiance’s, hostility toward family members, etc.)
-Assessment of psychiatric issues in the family (assessment should extend back to at least maternal/paternal grandparents).
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(12 points) Addresses less than 2 of the following areas or fails to address them with pertinent negative or similar statement(s):
-Discusses with clarity how members of the family interact with one another.
-Includes information on any family interaction difficulties (e.g., sibling rivalries, defiance’s, hostility toward family members, etc.)
-Assessment of psychiatric issues in the family (assessment should extend back to at least maternal/paternal grandparents).
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(6 points)
Past Medical History
(5 points) -Discusses any current or past medical issues/health concerns
-Describes course of pregnancy including complications/maternal health issues during pregnancy
-Were there any health issues during or following birth?
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(5 point) Addresses less than 3 of the following areas or fails to address them with pertinent negative or similar statement(s):
-Discusses any current or past medical issues/health concerns
-Describes course of pregnancy including complications/maternal health issues during pregnancy
-Were there any health issues during or following birth?
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(4 points) Addresses less than 2 of the following areas or fails to address them with pertinent negative or similar statement(s):
-Discusses any current or past medical issues/health concerns
-Describes course of pregnancy including complications/maternal health issues during pregnancy
-Were there any health issues during or following birth?
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(2 points)
Developmental Assessment
(10 points) -Discusses child/adolescents’ current stage of development.
-Presence of any developmental disorders.
-Assesses for presence of any traumatic events which could have (or had the potential to) impacted the child/adolescent
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(10 points) Addresses less than 3 of the following areas or fails to address them with pertinent negative or similar statement(s):
-Discusses child/adolescents’ current stage of development.
-Presence of any developmental disorders.
-Assesses for presence of any traumatic events which could have (or had the potential to) impacted the child/adolescent
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(8 points) Addresses less than 2 of the following areas or fails to address them with pertinent negative or similar statement(s):
-Discusses child/adolescents’ current stage of development.
-Presence of any developmental disorders.
-Assesses for presence of any traumatic events which could have (or had the potential to) impacted the child/adolescent
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(4 points)
Educational Assessment
(5 points) -Current grade in school
-Does child/adolescent have an individualized education plan (IEP)?
-Issues with truancy or other disciplinary issues at school?
-Evidence of bullying in school?
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(5 point) Addresses less than 4 of the following areas or fails to address them with pertinent negative or similar statement(s):
-Current grade in school
-Does child/adolescent have an individualized education plan (IEP)?
-Issues with truancy or other disciplinary issues at school?
-Evidence of bullying in school?
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(4 points) Addresses less than 3 of the following areas or fails to address them with pertinent negative or similar statement(s):
-Current grade in school
-Does child/adolescent have an individualized education plan (IEP)?
-Issues with truancy or other disciplinary issues at school?
-Evidence of bullying in school?
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(2 points)
Mental Status Examination
(20 points) AGE APPROPRIATE ASSESSMENTS OF:
-Assessment of appearance
-Assessment of orientation
-Assessment of adaptive functioning
-Assessment of attention & memory
-Assessment of fund of knowledge
-Assessment of insight
-Assessment of thought (coherence, speed, content, etc.).
-Assessment of mood
-Assessment of anxiety
-OTHER ASSESSMENT OF MENTAL STATUS PARAMETERS AS INDICATED.
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(20 points) Addresses less than 7 of the following areas or fails to address them with pertinent negative or similar statement(s):
AGE APPROPRIATE ASSESSMENTS OF:
-Assessment of appearance
-Assessment of orientation
-Assessment of adaptive functioning
-Assessment of attention & memory
-Assessment of fund of knowledge
-Assessment of insight
-Assessment of thought (coherence, speed, content, etc.).
-Assessment of mood
-Assessment of anxiety
-OTHER ASSESSMENT OF MENTAL STATUS PARAMETERS AS INDICATED.
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(16 points) Addresses less than 5 of the following areas or fails to address them with pertinent negative or similar statement(s):
AGE APPROPRIATE ASSESSMENTS OF:
-Assessment of appearance
-Assessment of orientation
-Assessment of adaptive functioning
-Assessment of attention & memory
-Assessment of fund of knowledge
-Assessment of insight
-Assessment of thought (coherence, speed, content, etc.).
-Assessment of mood
-Assessment of anxiety
-OTHER ASSESSMENT OF MENTAL STATUS PARAMETERS AS INDICATED.
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(8 points)
Neuropsychological Evaluation
(10 point) Assessment of child/adolescents:
-Cognitive strengths/weaknesses relative to same aged peers
-Linguistic strengths/weaknesses relative to same aged peers
-Assessment of interactions with examiner
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(10 point) Addresses less than 3 of the following areas or fails to address them with pertinent negative or similar statement(s):
Assessment of child/adolescents:
-Cognitive strengths/weaknesses relative to same aged peers
-Linguistic strengths/weaknesses relative to same aged peers
-Assessment of interactions with examiner
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(8 points)
Addresses less than 2 of the following areas or fails to address them with pertinent negative or similar statement(s):
Assessment of child/adolescents:
-Cognitive strengths/weaknesses relative to same aged peers
-Linguistic strengths/weaknesses relative to same aged peers
-Assessment of interactions with examiner
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(4 points)
Physical/Neurological Examination
(20 points) -Generalized assessment with emphasis on physical parameters, including:
-Height/weight
-Head, eyes, ears, nose, throat (HEENT)
-Cranial nerve testing
-Peripheral neurological exam (reflexes)
-Lungs (auscultate)
-Heart (auscultate)
-Abdomen (auscultate)
NOTE: Under NO CIRCUMSTANCES will you do a genital/rectal exam or any other exam maneuver requiring removal of clothing items- and while it may be a limitation, auscultation must take place over the clothing.
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(20 points) Addresses less than 6 of the following areas or fails to address them with pertinent negative or similar statement(s):
-Generalized assessment with emphasis on physical parameters, including:
-Height/weight
-Head, eyes, ears, nose, throat (HEENT)
-Cranial nerve testing
-Peripheral neurological exam (reflexes)
-Lungs (auscultate)
-Heart (auscultate)
-Abdomen (auscultate)
NOTE: Under NO CIRCUMSTANCES will you do a genital/rectal exam or any other exam maneuver requiring removal of clothing items- and while it may be a limitation, auscultation must take place over the clothing.
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(16 points) Addresses less than 5 of the following areas or fails to address them with pertinent negative or similar statement(s):
-Generalized assessment with emphasis on physical parameters, including:
-Height/weight
-Head, eyes, ears, nose, throat (HEENT)
-Cranial nerve testing
-Peripheral neurological exam (reflexes)
-Lungs (auscultate)
-Heart (auscultate)
-Abdomen (auscultate)
NOTE: Under NO CIRCUMSTANCES will you do a genital/rectal exam or any other exam maneuver requiring removal of clothing items- and while it may be a limitation, auscultation must take place over the clothing.
NOTE: If information about an area of the assessment is unable to be obtained, a statement addressing the area should be placed in the appropriate area of the assessment.
(8 points)
NEW ADMISSION WORKSHEET
IDENTIFICATION INFORMATION
Name: ¬¬¬¬____________________________ age: ____________ Date of admission: ____________________
Admission Status: 201/302: ______ Date of encounter: _________________ patient was seen and examined, chart reviewed and case discussed with clinical staff available at time of visit. Additional informants: ___________________¬¬¬¬¬¬¬_____________ REFERRAL SOURCE: _________________________________
CHIEF COMPLAINT/REASON FOR ADMISSION: __________________________________________
________________________________________________________________________________________
HISTORY OF PRESENT ILLNESS: ________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
PAST PSYCHIATRIC HISTORY/PREVIOUS PSYCHIATRIC VISITS¬¬¬¬¬¬¬¬¬¬¬ ___________________________
________________________________________________________________________________________________________________________________________________________________________________
PREVIOUS PSYCHIATRIC VISITS: _______________________________________________________
FAMILY HISTORY OF PSYCHIATRIC ILLNESS:___________________________________________
PREVIOUS PSYCHOTROPIC MEDICATIONS (include duration of each drug): __________________
________________________________________________________________________________________________________________________________________________________________________________
PAST MEDICAL HISTORY: ______________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
ALLERGIES: __________________________________________________________________________
CURRENT MEDICATIONS: ¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬______________________________________________________________
________________________________________________________________________________________
PSYCHOSOCIAL HISTORY: Marital status: ___________ Lives with: ______________ Children:______
Education: _______________________ Occupation: ______________________ Legal History: __________
Hx. of drug abuse: __________ History of Alcohol use/abuse: _______________ Smoker: ___________ History of physical/emotional/sexual abuse: _________Religion: ________
GENERAL WELL BEING:
-Patient reports that (she/he) is sleeping (well, poorly, fair). Indicates that (she/he) has trouble (falling asleep, staying asleep, waking up feeling as if she/he had not slept at all).
-Reports (low, fair, good) energy throughout the day. Patient acknowledges (poor, fair, good) appetite (if fair/poor, indicate how long this has persisted for).
EXAMINATION:
General appearance: The patient is of (average, stocky, healthy, petite) build and appears (stated age, healthy, frail) with (good, marginal, poor, disheveled, unkempt) grooming noted. Upon gross examination, patient appears to have no physical deformities (OR SPECIFY: hearing impaired, injured SPECIFY ).
Gait and Motor Coordination: Patient ambulates with a(n) (awkward, staggering, shuffling, rigid, trembling with/without intentional movement or at rest, lip smacking, tics), posture (slouched, erect),
Patient does/does not appear to be demonstrating any noteworthy mannerisms, gestures or tics (if so, specify, blinking, blepharospasm, facial twitches, grimaces, head jerking, abdominal tensing, shrugging or rotation of shoulders, jerking movements of extremities, grinding teeth [bruxism], oculogyric movements (OR IF SO, SPECIFY___________________________________________________________).
Activity level (increased, decreased or hypokinesis, or WNL).
Alertness: Patient is (sleepy, alert, dull and uninterested, highly distractible) and
oriented to (person, place, time, event).
Eye Contact patient (makes, avoids, seems hesitant to make) eye contact;
Rapport/Patient Demeanor: is (easy to establish, initially difficult but easier over time, difficult to establish, tenuous, easily upset). OR- Cooperative (Obsequious/solicitous/ effusive; seductive/flattering/charming; over-inclusive/eager to please; entitled/controlling). IF UNCOOPERATIVE: Hostile/defensive/ suspicious/guarded; antagonistic/critical; childish/regressed; sullen/withdrawn.
Manner and approach: Patient is (oppositional/resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness, distant, indifferent, unconcerned, evasive, negative, irritable, depressive, anxious, sullen, angry, assaultive, exhibitionistic, seductive, frightened, alert, agitated, lethargic, needed minor/considerable reinforcement and soothing) during the examination.
Facial and Emotional Expressions during the examination the patient appeared (relaxed, tense, smiled, laughed, became insulting, yelled, happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicious, tearful when discussing, mask-like or masked facies [absence of facial expression]) and
Anxiety During the clinical examination, patient (appeared anxious, did not appear anxious) as evidenced by: ______________). When directly questioned regarding anxiety, patient indicates the (she/he) (does, does not) worry about things in general (if specific source of anxiety, list: __________________________________), has (had, never had) intense fear or worry that something bad would happen to them. Further, patient indicates that there (is, is not) any specific things that frighten (him, her), if positive, describe: ________________________________________________________________________________________
Phobias/Specific phobias
-Do you have any strong fears about certain objects or situations?
-Are there objects or situations that make you intensely anxious if you cannot avoid them?
-Do you make special efforts to avoid certain objects or situations?
Social Phobias
-Do you have strong or persistent fears about being humiliated in public?
-Do you have strong or persistent fears that you will do something embarrassing in front of strangers?
Agoraphobia
-Do you require special arrangements to be made for you to feel comfortable when you’re outside your home?
-Do you have such a strong sense of anxiety that someone must be with you before you can leave your house?
-To what degree do you limit your activities because of anxiety?
Speech (normal rate and volume, pressured, slow, accent, enunciation, quality, loud, quiet, impoverished, goal directed); corprolalia (involuntary utterance of obscene words); anomia (inability to name or label things that are familiar);
Expressive Language demonstrates (no problems expressing self, circumstantial and tangential responses, anomia, difficulties finding words, misuse of words in a low-vocabulary-skills way, misuse of words in a bizarre-thinking-processes way, echolalia or perseveration, mumbling);
Flow of speech: Spontaneous/ hesitant/ interrupted/ halting
Receptive Language (normal, able to comprehend questions, difficulty understanding questions)
Mood or how they feel most days: Patient’s self-reported mood is (happy, sad, despondent, melancholic, euphoric, elevated, depressed, irritable, anxious, angry);
Affect or how they felt at the given moment (broad, restricted, blunted, flat, inappropriate, labile, consistent with the content of the conversation and facial expressions, pessimistic, optimistic)
Thought Processes demonstrated (Bizarre (describe: ___________________________________), looseness of association (irrelevance), flight of ideas (change topics), racing (rapid thoughts), tangential (departure from topic with no return), circumstantial (being vague, i.e., "beating around the bush"), word salad (nonsensical responses), derailment (extreme irrelevance), neologism (creating new words), clanging (rhyming words), punning (talking in riddles), thought blocking (speech is halted), and poverty (limited content); confabulations, grandiosity, magical thinking, obsessions, perseveration, REPORTS OF DEPERSONALIZATION: __________________________________________________________________
Though Content:
Delusions
1. What is been on your mind recently?
2. Do you spend a lot of time thinking about one or two things?
3. Do you have some ideas that you hold very strongly?
4. To others frequently disagree with your views on things?
5. When you are busy with something, what do you think about?
6. One of the things that are most important to you?
7. Have you ever felt someone was reading you mind or making you think things?
(Paranoia)
-When you enter a building or get on a bus, does everyone turn to look and watch you.
-Do you think someone is out to get or harm you, or is plotting against you?
-Have you ever done something unusual, and thought someone might have drugged you to make you do it?
Other Delusional Thought Processes:
Patient demonstrates: Grandiose/Delusions of grandeur/ Delusions of jealousy/ Erotomanic delusions [de Clerambault’s syndrome or "phantom lover syndrome"]/ Somatic delusions (delusions of odor/delusions of infestation/delusions of appearance)/ delusions of passivity or control: delusions of control (thought broadcasting/thought insertion/ thought withdrawal), thought processes.
Rarer Delusional Thought Processes: capgras syndrome (imposter replaced someone significant to the patient and has an identical appearance); delusion of reference (ascribing personal meaning to, events-radio has special message, just for the patient)- if held to a lesser degree, use "ideas of reference". Doppelganger (having a double); Dorian Gray ( person stays same age, while everyone else, ages); Enosimania (guilt, worthlessness, for having committed some catastrophic deed); magical thinking (building and event will occur because the person thought about it); messianic (the person thinks they are God); Mignon (being over a lineage); nihilism(nonexistent; loss of organs, body, or everything; sense of death or disintegration); phantom border (unwelcome delusional houseguests); poverty (loss of wealth and property);
Specify whether or not delusions are ego-syntonic (not for in our distressing to patients) or ego-dystonic (for in our distressing to patients).
Overvalued Ideas- less firmly held than delusions; content is less absurd; not systematized-superstitions are magical thinking
Obsessions- (Compulsions and Obsessions)
-Do you experience repetitive thoughts that you can stop?
-Do they feel like your own thoughts?
-Are you ever forced to think about something against her will?
-You have intrusive thoughts about … (Contamination, hurting someone, having to count something)?
-Administer YBOCS if positive
Hallucinations and Delusions:
-Have you ever felt your mind was playing tricks on you?
(presence, absence), if present (delusion of jealousy, delusion of infidelity, erotomanic delusion, somatic delusions [delusion of odor, infestation, dermatozoic, appearance], delusion of passivity, delusion of control). , denied visual but admitted olfactory and auditory, denied but showed signs of them during testing, denied except for times associated with the use of substances, denied while taking medications-_________________ ________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________
Hallucinations appear to be (Egosyntonic, Egodystonic).
Coherence (responses were coherent and easy to understand, simplistic and concrete, lacking in necessary detail, overly detailed and difficult to follow)
Suicidal and Homicidal Ideation (denies, ideation but no plan or intent, clear/unclear plan but no intent, ideation coupled with clear plan and intent to carry it out);
Recall and Memory- patient appeared to be a (good, reliable, poor) historian. *could explain recent and past events in their personal history; recalls three words (e.g., Ball, tree, and boy) immediately after "X" rehearsals, and then again five minutes later.
Concentration and Attention are (grossly intact, impaired ) based on patients (ability/inability) to count backwards from 100 by serial 7’s, OR spell the world "WORLD" in reverse).
Insight: ASSESSSMENT QUESTIONS:
-Is it your opinion that you have an illness?
-How do you account for the difficulties that you have been having?
-Have you had experiences that you think aren’t normal?
-What does (name of condition) mean to you?
-What is important to help your recovery?
-What will happen if you don’t follow through with the treatment proposed for this condition?
-What would help you to feel better?
DOCUMENTATION: Patient demonstrates full insight (recognizes that signs and symptoms are part of an illness, is able to modify behavior and can fully cooperate with treatment). PARTIAL INSIGHT (recognizes that there are problems but does not attribute them to an illness, may understand others [family, doctor] but sees them as ill, some ability to modify behavior, variable degree of cooperation with treatment). IMPAIRED/NO INSIGHT (denial of illness or that there are problems, has no capacity to understand the concerns of others, poor compliance with treatment).
Judgment: Is (grossly intact, impaired) based on (appropriate, inappropriate) explanations of :
-Ask the patient "how did you come to seek medical attention?" (how did he/she enter the mental health system).
-How long did the person wait before seeking help?
-How bad did things get before the patient got assistance?
-Did the person seek assistance of his or her own volition?
-To what extent were others A(e.g., the police3) needed to motivate or push the patient into getting assistance?
-Were there associated medication problems?
-Did others suffer harm because of the patient’s actions?
-What was the "final straw" that resulted in action being taken?
OTHER DIRECT QUESTIONS:
-"What are your plans for the future?"
-"What would you do if you became acutely suicidal?"
-"What are the first signs that you are aware of when things are starting to go downhill?"
-"What would you do about them?"
Impulsivity: Patient acknowledges impulsivity as evidenced by the realization that (low medium, high)
-Do you ever find yourself suddenly doing something before you have really had a chance to think about it?
-Do you ever do things you had decided not to do, and don’t know why?
-Does money "burn a hole in your pocket"?
Intellectual Ability- general fund of knowledge (roughly average, above average, or below average) based on (correct/incorrect) answers to (circle which questions you asked): 1. "what is the name of the current & last president," 2. "who is the governor of the state," 3. "what is the capitol of the state," 4. "how many nickels are there in a dollar", 5."Name 5 major United States cities".
Abstraction Skills: Abstract thinking abilities appear (intact/impaired) as patient was (able/unable) to tell me the meaning of the following proverbs (indicate which questions you asked):
1. "What do people mean when they say "a rolling stone gathers no moss";
2. What do people mean when they say "strike while the iron is hot";
3. What do people mean when they say "when the cats away; the mice will play";
4. What do people mean when they say "the bigger they are, the harder they fall"
5. What do people mean when they say "what goes around, comes around?"
6. What do people mean when they say "Don’t judge a book by its cover";
7. What do people mean when they say "Two wrongs don’t make a right";
8. What do people mean when they say "Don’t count your chickens before they hatch"
As well as the patients (ability/inability) to explain the following similarities (1. "How is a tree and a housefly alike?" 2. How is a train and a car alike? 3. How is an apple and an orange alike), and the (ability/inability) to give alternate meanings for words such as 1. "right", 2. "bit", and 3. "left".
Visuospatial ability: Patient (demonstrated, did not demonstrate) evidence of constructional apraxia as evidenced by inability to replicating a drawing of interlocking pentagons. IF THAT FAILS, HAVE THEM DO THE CLOCK DRAWING TEST
Response to Failure on Test Items: The patient seemed to be (unaware, frustrated, anxious, obsessed, unaffected) when they learned that they performed poorly on test items.
SPECIAL CONSIDERATION QUESTIONS
(Depression)
– Administer GDS.
(Delusions and Hallucinations)
-Have you ever felt someone was reading you mind or making you think things?
-Have you ever felt your mind was playing tricks on you?
-Have you ever had a dream that was so intense and real, your weren’t sure if you were asleep or awake?
(Mania)
-If suspected, administer either Young Mania Rating Scale or Altman Self-Rating Mania Scale
(Eating Disorders)
-Do you think that your eating habit are unusual?
-What is your weight now?
-What is the most and least you’ve weighed?
-Are you concerned about your weight?
Assets & Strengths: Patient has a place to return upon discharge (AND, IF APPLICABLE): At the time of admission, patient is physically capable of participating in the milieu of the program and there are no current limitations that would prevent active participation in unit programming. AND, IF APPLICABLE- Patient has support of family/significant others.
Weaknesses: Limited insight— [FOR ECT ADMISSIONS, USE: failure of multiple treatment strategies]
DIAGNOSTIC IMPRESSION:
Axis I: Clinical syndromes that are the focus of the diagnosis
Axis II: Long standing chronic conditions that may affect the clinical syndromes listed in Axis I (personality disorders)
Axis III: Medical conditions
Axis IV: Psychosocial and environmental stressors that may affect the clinical syndromes listed in
Axis I
Axis V: GAF Score (1 – 100)
PLAN OF TREATMENT:
1. Admit to Senior Medical Mental Health Unit. 2. Individual, group and milieu therapy. 3. Review of records. 4. Psychotropic medications as required. 5. Psychological testing as required. 6. Complete history and physical as well as appropriate blood work, EKG & CXR as deemed necessary by the medical attending. 7. Psychosocial assessment. 8. Nursing assessment. 9 Visits by psychiatry.
PROGNOSIS: Good/fair/poor (based on): __________________________________________________
ESTIMATED LENGTH OF STAY: 5 to 7 days
DISCHARGE CRITERIA: The patient will be discharged when S/HE is no longer a risk to HIM/HER self or others and has met the criteria set forth by the treatment team for discharge.
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