Reliability, judgment, and insight The following reports are provided as samples. Mental Status Report 1 Gary Sparrow, a year-old white male, was disheveled and unkempt on presentation to the hospital emergency room. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age.
During the interview, he was agitated and restless, frequently changing seats. He was impatient and sometimes rude in his interactions with this examiner.
Sparrow reported that today was the best day of his life, because he had decided to join the professional golf circuit. His affect was labile, but appropriate to the content of his speech i.
His speech was loud, pressured, and overelaborative. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life.
Sparrow described grandiose delusions regarding his sexual and athletic performance. He reported auditory hallucinations God had told him to quit his job and become a professional golfer and was preoccupied with his athletic and sexual accomplishments.
He was oriented to time and place, but claimed he was the illegitimate son of Jack Nicklaus. He denied suicidal and homicidal ideation.
He refused to participate in intellectual- or memory-related portions of the examination. Sparrow was unreliable and exhibited poor judgment. Mental Status Report 2 Ms. Her grooming was adequate and she was cooperative with the examination.
Her speech was slow, halting, and soft. You know, I have lots of visitors coming by later. Jackson was oriented to person and place, but indicated the date as January 9, today is July 8, Judgment, reliability, and insight were significantly impaired.
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|Contact Author Common Types of Mental Health Assessments Mental health assessments MHAs are used for a number of situations, including criminal and family court cases; disability claims workers compensation, veterans benefits, Social Security, the Public Employees' Retirement Systemaccident claims for companies, and evaluations in school settings. In over two decades, I have found many of these assessments to contain similar elements.|
The latest edition 4th edition, updated of Clinical Interviewing also includes a DVD with me John demonstrating a mental status examination.When diagnosing a mental illness and determining an appropriate course of treatment, mental health practitioners commonly compose a psychological assessment report.
List the patient name, case number and dates of your assessment. Jun 13, · How to Write an Assessment for Social Work. In this Article: Article Summary Gathering information Writing the Assessment Community Q&A A social work assessment is a report written by a social worker evaluating a client’s educational, mental health, substance abuse, or occupational needs%(39).
Two Sample Mental Status Examination Reports. August 10, Mental Status Report 1. Gary Sparrow, a year-old white male, was disheveled and unkempt on presentation to the hospital emergency room. I think that’s a reasonable way for mental health professionals to work.
Thanks again for your comments, the opportunity to learn from . Psychology Documentation Samples In an effort to continue to enhance Provider knowledge of documentation requirements, MHD has prepared Sample Documentation for review. MHD has no prescribed format for documentation however, the content is required when providing services to ANY MHD participant regardless of Prior Authorization.
Essentials of Assessment Report Writing provideshandy, quick-reference information, using the popular Essentialsformat, for preparing effective assessment reports. This book is designed to help busy mental health professionalsquickly acquire the knowledge and skills they need to writeeffective psychological assessment reports/5(36).
Oct 22, · Mental health assessments (MHAs) are used for a number of situations, including criminal and family court cases; disability claims (workers compensation, veterans benefits, Social Security, the Public Employees' Retirement System), accident claims Reviews: 6.