INTRODUCTION

There are quite a few issues that are looked into when a professional is assessing someone, usually a GP or Psychiatrist. In order to obtain the relevant information in order to gain the correct diagnosis the areas below are reviewed against the individual is used for Psychiatric Assessment:

  • Identifying Information
  • Main Complaint or Problem
  • History of Same
  • Medical History
  • Social History
  • Family History
  • Past History
  • Mental Status
  • Physical Examination
  • Psychometric Tests.

Please continue for a more detailed description under each of the above sub-headings.

IDENTIFYING INFORMATION

  • Age
  • Sex
  • Religion
  • Ethnicity
  • Marital Status
  • Next of Kin
  • Address
  • Others at same address
  • Occupation
  • Education
  • Number of Admissions

MAIN COMPLAINT

It is important to assess in the clients own words the reasons for seeking (informal admission) or to be sent (detained) to hospital for treatment or assessment (whichever is more appropriate or relevant).

HISTORY OF COMPLAINT

  • Date of Onset
  • Events leading to Onset
  • Precipitants
  • Formation of Symptoms
  • Conditions under which the symptoms emerge.
  • Reactions of others to client

SYMPTOMS

CHANGES IN FEELING

  • Depression
  • Elation
  • Mood (lability)
  • Anxiety
  • Fear/s
  • Nihilism
  • Guilt
  • Emptiness
  • Coping efficiency

CHANGES IN COGNITION (KNOWING)

  • Orientation
  • Memory
  • Concentration
  • Attention
  • Delusions
  • Phobias
  • Obsessions
  • Ideas of Reference
  • Paranoia
  • Grandiosity
  • Judgement

CHANGES IN BEHAVIOUR

  • Volition
  • Activity
  • Motor Retardation
  • Impulsiveness
  • Aggression
  • Suicidal Ideation
  • Drug / Alcohol Abuse
  • Relationships
  • Sex

CHANGES IN PERCEPTION

  • Hallucinations (type)
  • Depersonalisation
  • De-Javu
  • Illusions

CLIENTS TREATMENT GOALS

  • Sleep Pattern
  • Weight Change
  • Appetite
  • Libido

PAST HISTORY OF PSYCHIATRIC CONTACTS

Note for each contact:

  • Dates
  • Agency
  • Diagnosis
  • Precipitants
  • Treatment
  • Progress.

MEDICAL HISTORY

  • Childhood Illnesses
  • Major Medical / Surgical problems and treatments,
  • Accidents / Traumas
  • Neurological Problems
  • Head Injuries
  • Fevers
  • Convulsions / Seizures
  • Headaches / Migraines
  • Visual Disturbances
  • Disorientation
  • Tremors
  • Tics.

ENDOCRINE PROBLEMS

  • Thyrotoxic
  • Pituitary
  • Adrenal
  • Allergies
  • Alcohol Consumption
  • Current Medication

FOR WOMEN

  • Age at Menarche
  • Menstrual Cycle
  • Contraceptive use
  • Pregnancies etc.

SOCIAL HISTORY

This includes social and developmental history.

Symptoms of behavioural problems:

  • Temper- Tantrums
  • Headbanging
  • Enuresis
  • Cruelty to Animals
  • Mutism
  • Hyperactivity

INTERACTIONS WITH OTHERS

  • Dreams and Memories
  • Friends
  • School
  • Puberty
  • Sexual Development

PROBLEMS OF ADOLESCENCE

  • Running from Home
  • Drug Abuse
  • Self Image
  • Religion

WORK HISTORY

  • Unemployment etc,
  • Satisfaction
  • Finance
  • Social Activity
  • Living Conditions

FAMILY HISTORY

  • Family Members
  • Description each Nuclear member
  • Relationships
  • Amount of Contact.

MENTAL ASSESSMENT

APPEARANCE

  • Dress
  • Posture
  • Facial Expression
  • Motor Activity
  • Mannerisms

EMOTIONAL STATE

  • As above under symptoms

SPEECH CONTENT

  • Quantity
  • Quality
  • Organization

NON-VERBAL COMMUNICATION

  • Mannerism
  • Posture

STATE OF CONSCIOUSNESS

  • Thought Content
  • Perceptual State
  • Dreams

ATTITUDE

  • Cooperation
  • Reliability
  • Motivation
  • Insight
  • Eye Contact

For a more complete set of criteria see under ‘symptoms’ in section headed HISTORY OF COMPLAINT.

PHYSICAL EXAMINATION

FULL SYSTEM REVIEW

  • FBC
  • Thyroid Test
  • LFT
  • Routine Urinalysis
  • Chest Xray
  • Skull Xray
  • ECG
  • EEG
  • Kidney Studies
  • U&E

PSYCHOMETRIC TESTS

  • I.Q. Tests
  • Personality Profile
  • Mini Mental State
  • Depression Scale
  • Dependency Scale

PRE-ADMISSION ASSESSMENT AND FORM

Assessments should not start at the point of admission. The Assessment should begin with the first telephone Referral. Questioning should begin by the appropriateness of the referral to the client group of the Home, and be in line with the Homes Aims and Objectives. Even if the telephone conversation leads to the belief that the prospective client may be unsuitable, it is always sensible to see the person referred and make a formal Pre-Admission Assessment.

Basic details need recording commencing with the client’s name, date of birth, who has referred them and date, who is to do the assessment and on what date, and who was present. The client’s current address, Consultant, G.P., Social Worker and C.P.N need to be recorded. A brief description of their present care is also required. Due to funding requirements, issues of Preserved Rights and agreed funding have to be identified, and which type of care that is being offered. A diagnosis for the client and what the presenting problem is will aid the assessor in establishing whether or not the prospective client is suitable for admission to the Home

MOBILITY

This is an issue with the Mentally Ill, the Home must decide whether a client can be accommodated if there are difficulties, corridors may not be wide enough for wheelchairs without a risk to Health and Safety. The Home may be an active one and mobility may be of prime importance, or conversely, a Home may have the ability to care for a less mobile client, and may see the client as totally appropriate. The important point is that the decision to admit is in the best interests of the client, other clients in the Home and the Home itself.

PERSONAL CARE

This is an issue, which affects this client group. It is one of the first parts of a person’s dignity that becomes neglected once an illness takes place. Knowledge of the depth of need for personal care, including hygiene, means that the Home will give attention to the client and ensure that it forms the appropriate responses in the Care Plan.

DAILY LIVING SKILLS

The skills gained will enable the client to live as independently as possible within the Home. Any inability to manage can lead the Home to make efforts to improve the clients abilities, as the better they can manage, and the more their self esteem rises, the Home will be seen as pro-active and improve or maintain its reputation in the field.

HEALTH PROBLEMS

Health Problems need investigating, as there may be issues regarding diet, medications, dressings, special equipment, the ability to communicate and other reasons that must be taken regard of if a successful admission is to take place. Health problems once recognised, may be major or minor, once understood can be dealt with adequately.

SENSORY LOSS

This can in itself lead to a form of Mental Illness. It can make the client fearful of sounds if sight is affected, or misunderstand light formation, i.e. believe a Grandfather clock is a person, or someone with Hearing loss may believe others are talking about them. If they suffer Tinitus this may increase their delusional thoughts.

SOCIAL BEHAVIOUR

The client must be socially acceptable to the Home and its other clients; otherwise disruption can take place. If there is a known behavioural problem, then the question must be whether the Home can control and manage that behaviour. Their communication skills should be relevant to their place in the Home. If they are confused, is this a suitable place to live. If they have a tendency to wander, has the Home adequate security to manage this behaviour. At what level can behaviour be accepted that is upsetting to other clients? Is social isolation a problem, or is it acceptable for clients to stay in their own room all day. If they smoke, are they a fire risk, or will the burn their clothes or the Homes furnishings and devalue its quality? If they enjoy alcohol, how much and does it make them aggressive or incontinent, and will it affect their medications.

MENTAL STATE

Is the person referred mentally stable, are they in fact in need of admission to an Acute Unit, but are being referred to the Home because of other issues? If they are admitted to the Home, will their symptoms affect others, including the rest of the Community? A mistake may cost the Home local goodwill.

CURRENT MEDICATION

This will be required to be known as it will affect the mental state of the client, oral medications, tablets or liquid, injections, creams or other forms. A mental note may make the enquirer believe the medication appears about right, or too much or too little. If the client is moving to a new Doctor, then these points may need to be raised.

If suitable a date is made for the client to visit the Home, and how they will get to and from the Home. At the time of the Assessment, the client should be given information about the Home, i.e. brochure, later a note should be made in the Homes diary that a visit is to take place, and details should be recorded in the referral book. Information about the prospective client should be handed over to the next shift. The Assessor should then sign and date the form and state their designation.

The outcome of the Assessment should be made at the end of the form, whether to admit or not. If to be admitted, what date and whether Residential, Nursing, or Social Support. If not, the Assessor should give their reasons, and again date, sign with their designation. The form is then complete.

ADMISSION / DISCHARGE REGISTER

It is a requirement of the the Care Standards Commission that all Homes keep a register of all admissions and discharges that the Home has. The form is generic and is kept in a specific file which the Registration and Inspection Authority seeks to view at each Inspection. The information required is:

  • Name
  • Admitted From
  • Date of Birth
  • Marital Status
  • Next of Kin
  • General Practitioner
  • Date of Admission
  • Admission Authority
  • Date of Discharge
  • Discharge Address
  • Date of Transfer
  • Address and Reason (for transfer)
  • Date, Time Cause of Death (when death occurs)
  • Section / Order (if relevant)

RESIDENT PERSONAL PROFILE

This form covers similar information as above but is an individual form, which is in the individuals file. It also contains information regarding medications and their National Insurance number.