A mental health assessment form is a document used by healthcare professionals to gather information about a patient's mental health status. It helps in understanding the patient's thoughts, feelings, behaviors, and overall mental well-being.
Mental health assessment forms are indispensable tools for psychologists in Great Britain and worldwide. They perform a range of functions, including:
- Facilitate comprehensive evaluations
- Aid in diagnosis and treatment planning
- Ensure legal and ethical compliance
- Support collaboration among healthcare professionals
- Contribute to research efforts
- Assist in insurance processes
- and enable a holistic approach to mental healthcare.
Today, we will discuss the main diagnostic methods reflected in assessment forms, the principles of their completion, the structure (with a template), and the legal aspects of the issue.
History-Taking in Psychiatry
History-taking comprises information gathered during a medical examination by questioning the patient and people familiar with him.
At Medesk, information about each patient is stored in an individual electronic medical record. It allows you to view all the services rendered to him during the treatment at the clinic. The attending physician can get acquainted with the patient's medical history, view all the appointments and reports that were written by other doctors, as well as compare the results of current and previous analyses of the patient.Open the description >>
Understanding a patient's history is tricky because people with mental issues can distort facts. They might lie or forget details. So, psychiatrists gather information not just from patients (subjective history) but also from others (objective history) to cross-verify.
In cases where patients can't provide reliable information, such as when they're confused or have severe cognitive impairment, consulting their family or checking their past can give vital clues about their mental health.
Anamnestic information encompasses the following aspects.
Anamnesis of life
This section outlines key life stages, beginning with pregnancy. These specific life history sections are significant for mental health professionals:
- Pregnancy details
- Childbirth specifics
- Early childhood development: milestones like speaking, walking, social interactions, and preschool experiences
- School years: school entry, academic performance, social interactions, physiological changes
- Later stages: education, hobbies, social life, work, military service, menopause, pregnancies, driving, criminal record
Allergy history and medication side effects
This is essential across medical disciplines, given the potential for adverse reactions to medications.
Heredity plays a significant role in many mental disorders. This section explores specific disorders and the family's medical history, including the causes of relatives' deaths (e.g., increased risk of suicidal behavior in obsessive-compulsive disorder).
Past and concurrent medical conditions
While it holds general medical and organizational importance, this section can also aid in diagnosis and partially overlap with the disease history section. For example, hypertension may heighten the risk of vascular dementia, and traumatic brain injuries may lead to anxiety disorder.
This section may also intersect with disease history (addiction syndrome or the consequences of substance abuse causing organic brain damage).
Among the most critical sections, it reveals several diagnostic facets:
- The mental illness
- Causative factors (head trauma consequences)
- Illness duration
- Course type (continuous or episodic)
- Characteristic symptoms,
- and treatment adherence.
It also notes the circumstances of hospitalization or psychiatric assessments, like self-assessment, court-ordered assessments, or referrals from other specialists. Additionally, it may reflect the patient's attitude towards their condition.
These comprehensive sections contribute to a more thorough and accurate psychiatric assessment, enabling healthcare professionals to make informed diagnoses and treatment decisions.
Another assessment tool reflected in the mental health form is the clinical interview.
The interview differs from usual questioning in that it is aimed not only at a person's complaints but also at identifying the hidden motives of a person's behavior and helping him to realize the true (internal) reasons for mental health problems.
Before conducting a clinical interview, it is recommended to gather as much information as possible about the patient from objective (non-patient-reported) sources. For instance, from medical records, family relationships, and caregivers, compile an objective medical history. This information will assist in various aspects during the interview:
- Put forward hypotheses that can be tested during the interview
- Identify missing components that can be clarified during the interview
- Focus attention on the most important symptoms and syndromes of the disorder that resulted from the anamnesis
- Assess the patient's criticism, his tendency to simulate or dissimulate
- Give a reason to start a dialogue.
The main objectives of clinical interviewing are:
- Assessment of the individual psychological characteristics of the patient.
- Ranking of identified features by quality, strength, and severity.
- Attributing them to psychological phenomena or to psychopathological symptoms.
Patients often struggle to accurately describe their condition and articulate their complaints and problems. That's why the ability to listen to a person's issues is only one part of the interview. The other part is the ability to tactfully help them articulate their problem, understand the roots of their psychological discomfort, and capture them in an assessment form.
The result of a clinical interview may be the registration of the patient's mental status. Mental status is a description of the state of a person's psyche, including his intellectual, emotional, and physiological capabilities.
The mental status is descriptive and informative in nature, with the reliability of a psychological (psychopathological) "portrait" and from the standpoint of clinical information.
So, history taking provides a broad overview of the patient's background and context, while clinical interviewing delves into the current mental and emotional state of the patient through direct interaction. Both components are crucial for a comprehensive mental health assessment, helping clinicians understand the patient's history as well as their current psychological condition.
Mental Health Assessment Template
The information collected through this form assists clinicians in making accurate diagnoses and developing appropriate treatment plans. While specific mental health assessment forms may vary based on the healthcare provider or institution, a general form typically includes the following sections.
At the Medesk medical information system, you can create any report templates that make it easier for the doctor to fill out the card and allow him to devote more time to the patient.Learn more >>
- Date of Birth
- Phone Number
- Emergency contact information
- Description of the main issue or reason for seeking a mental health assessment.
- Current and past medical conditions
- Current medications
- Past surgeries or hospitalizations
- Past diagnoses (if any)
- History of psychiatric treatments (therapy, counseling, medications)
- Family history of mental health issues
- Alcohol consumption
- Illicit drug use
- Prescription drug use and abuse history
Mental health symptoms
- Description of current symptoms (e.g., mood changes, anxiety, sleep disturbances)
- Duration and intensity of symptoms
- Triggers for symptoms
Social and family history
- Relationships with family members and significant others
- Educational background and employment status
- Housing and living situation
- Day-to-day life
- Legal or financial issues
- History of physical, emotional, or sexual abuse
- Traumatic events experienced
- The clinician's observations about the patient's appearance, behavior, and speech during the assessment.
- Suicidal thoughts or self-harm behaviors
- Homicidal thoughts or violent tendencies
- History of suicide attempts
Diagnosis and treatment plan
- Provisional diagnosis (if applicable)
- Recommended treatment approach (therapy, medication, hospitalization, etc.)
- Referrals to specialists, if needed
Patient's goals and preferences
- Patient's expectations from the treatment
- Preferences regarding therapy, medication, or other interventions
- Information about the confidentiality of the assessment and its limits.
It's important to note that mental health forms should be used and stored following strict confidentiality and privacy guidelines to protect the patient's sensitive information. Additionally, the questions in the form should be designed to be sensitive, respectful, and non-stigmatizing to encourage open communication between the clinician and the patient.
Electronic Mental Health Assessment Form
Gathering relevant information about a patient's mental and physical health can be faster and more efficient with the help of electronic health records.
Through the patient portal, your patients can not only fill out necessary forms online and send them to you but also book appointments and make payments without leaving their homes.
The accuracy of the assessment and the correct diagnosis depend on the specialist's immersion in the patient's case. Deep connection and mutual understanding can be achieved when a doctor is not constantly distracted by filling out paperwork during appointments but instead gives proper attention to the patient. In the case of mental health services, delicacy and heightened attention from the specialist are a must.
Modern practice management software provides the opportunity to deliver high-quality mental health support by automating all routine tasks that can consume valuable time.
Visit our blog to learn more about how PMS can elevate your private practice and improve the quality of care for your patients.