assessment_lec

Assessment_lec - ASSESSMENT AND DIAGNOSIS INTAKE ASSESSMENT REASONS FOR REFERRAL AND ASSESSMENT(including"chief complaint HISTORY OF CURRENT

Info iconThis preview shows pages 1–3. Sign up to view the full content.

View Full Document Right Arrow Icon
ASSESSMENT AND DIAGNOSIS INTAKE ASSESSMENT REASONS FOR REFERRAL AND ASSESSMENT (including "chief complaint") HISTORY OF CURRENT PROBLEM (including precipitants, stressors, symptoms, duration of symptoms, etc) CLIENT SOCIAL HISTORY (current living situation/ marital/ employment/ financial circumstances) FAMILY HISTORY (incl. history of abuse--physical, sexual; family psychiatric history) LEGAL HISTORY SUPPORT NETWORK (Any friends or family? church membership? Are other agencies involved?) MEDICAL AND PSYCHIATRIC HISTORY - History of Medical Illnesses (incl. surgeries) - Psychiatric History (inpatient/outpatient treatment?) - All Current Medications (including dosage, effectiveness; side effects) - All Past Medications (incl. dosage, effectiveness, side effects) SUBSTANCE ABUSE HISTORY - Assess for each substance and when substance was last used (including alcohol, coffee, cocaine, marijuana, prescription drugs, etc.) - Former Alcohol/Drug Treatment? MENTAL STATUS EXAM (see next page for a complete mental status exam outline) DIAGNOSTIC IMPRESSIONS (DSM-IV - on all five axes) RECOMMENDATIONS - e.g., medication evaluation, further assessment, psychotherapy, hospitalization
Background image of page 1

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
MENTAL STATUS EXAM GENERAL APPEARANCE AND BEHAVIOR: - Grooming (e.g., neat, unkempt, odiferous, etc.) - Facial Expression (e g., happy, tense, etc.) - Activity Level (e.g., overactive, underactive, etc.) - Posture (e.g., erect, relaxed, slouched, etc.) - Gait (.e.g, natural, stiff, shuffling, etc.)
Background image of page 2
Image of page 3
This is the end of the preview. Sign up to access the rest of the document.

This note was uploaded on 07/16/2009 for the course PSC 168 taught by Professor Zane during the Fall '07 term at UC Davis.

Page1 / 7

Assessment_lec - ASSESSMENT AND DIAGNOSIS INTAKE ASSESSMENT REASONS FOR REFERRAL AND ASSESSMENT(including"chief complaint HISTORY OF CURRENT

This preview shows document pages 1 - 3. Sign up to view the full document.

View Full Document Right Arrow Icon
Ask a homework question - tutors are online