Assessment

IS THE FIRST STEP of the nursing process and involves the collection, organization, and analysis of information about the client’s health. In psychiatric–mental health nursing, this process is often referred to as a psychosocial assessment, which includes a mental status examination. The purpose of the psychosocial assessment is to construct a picture of the client’s current emotional state, mental capacity, and behavioral function. This assessment serves as the basis for developing a plan of care to meet the client’s needs. The assessment is also a clinical baseline used to evaluate the effectiveness of treatment and interventions or a measure of the client’s progress.
Part 1: Biopsychosocial History
A. Identifying Client’s Information (Demographic Data)
Age, gender, marital status, education, occupation, and current living situation (live alone or with family).
B. Chief Complaint
The current reason of contact or seeking mental health services. (e.g. what brings you here today?).
C. History of Present Illness:
Client’s symptoms including (onset of symptoms, duration, and symptoms stability).