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Mental Status Examination and Documentation

Author: Tikvah Portnoi, LICSW

A mental status evaluation is a necessary part of any client assessment no matter what the presenting problem. It should be documented in the record either in list form or in narrative form. This article illustrates both the list and the narrative. The following client functions should be included.


1. Appearance - included facial expression, grooming, dress, gait, etc.

2. Orientation - includes awareness of time and place, events, etc.

3. Speech Pattern - describes the speech, i.e., slurred, pressured, slow, flat tone, calm, etc.

4. Affect/Mood - describes mood as evidenced in both behavior and client’s statements - i.e. sad, jittery, manic, placid, etc.

5. Impulsive/Potential For Harm - assesses impulse control with special attention to potential suicidality and/or harm to others.

6. Judgment/Insight - describes client’s ability to predict the consequences of her/his behavior, to make "sensible” decisions, to recognize her/his contribution to her/his problem.

7. Thought Processes/Reality Testing - describes client’s thinking style and ability to know reality, including the difference between stimuli which are coming from inside herself/himself and those which are coming from outside herself/himself. Statements about delusions, hallucinations, and conclusions about whether or not the client is psychotic would appear here.

8. Intellectual Functioning/Memory - a description of level of intelligence and of recent and remote memory functions.

A paragraph about mental status in the record might read something like this:

Client is a 43 year old woman who looks older than her stated age. She is well groomed and appropriately dressed for a professional interview. She is well oriented. Her speech is slow and labored as if it is painful to talk. She has had occasional thoughts of "ending it all” but has not made any suicidal plans or preparations. She talks about future events with expectation to be alive. She is aware that she is "depressed” and recognizes that the source of some of the feeling comes from "inside moods” although she often refers to the difficulties of her situation. Her thoughts are organized and well presented wit very good vocabulary. She is not psychotic.

A brief paragraph about this client might read as follows:
This 43 year old woman of better then average intelligence dresses appropriately, is oriented and talks in a labored way. She appears depressed but is not actively suicidal. Judgment is adequate and she is not psychotic. Impulses are controlled.

Managed care companies often have expectations about how the mental status should be documented in the record. These should, of course, be followed.

The mental status, though not the only part of client assessment, is a major and essential piece of any client evaluation. The clinician who has in mind the components of the mental status can likely assess a client in the first interview. This will contribute essential information to the initial evaluation and makes possible the development of goals and treatment plans very early in the contact.

 

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