Overview of Mental Status Assessment:

Assessment of mental status, in it’s entirety may not be routinely done by the nurse for all patients, maybe necessary in some instances, example when assessing the patient for the first time,¬† or when there is a need to establish the patient’s mental state. Portions of mental health assessment will be routinely assessed by nurses in almost all healthcare settings because the patient’s mental health state is an integral aspect of the patient’s overall health status. This chapter will provide the learner a guide on howto perform a comprehensive mental health assessment and document findings. The nurse will eventually adjust the assessment according to specific situations and healthcare settings.

Objectives: At the end of this chapter:

  1. use  a holistic approach in obtaining a mental status assessment.
  2. Obtain mental health history.
  3. Perform mental status examination
  4. Utilize therapeutic communication techniques to obtain a mental health history and mental health examination.
  5. Document the mental status examination.

 Importance of Mental Health

How to Assess Mental Health Status

Tools to Assess Mental Health Status

 Documentation

The standard format for documenting the Mental State Examination varies a little, but as long as all areas are covered the exact order is not crucial.

Format for documenting the Mental State Examination:

  • Appearance and Behaviour
  • Speech
  • Mood
    • Subjective
    • Objective
  • Risk
  • Thoughts
    • Form
    • Content
  • Beliefs ‚Äď Overvalued or Delusional
  • Perceptions
  • Cognition
  • Insight

Related Laboratory and Diagnostic Tests ( Assessment Tools in Mental Status Assessment)

Overview of Assessment Tools for Mental Status Assessment and Screening of Behavioral Problems

 

VI. Learning Exercises

  1. List 10 medical terminologies used in mental status assessment.
  2. Document a mental status exam done on a patient,

 

VII Citation and Attribution

CDC   https://www.cdc.gov/mentalhealth/learn/index.htm

AAP   https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Documents/MH_ScreeningChart.pdf

License

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Guide to Health Assessment for Nurses Copyright © by Raki Bertiz and Ching-Chuen Feng is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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