Mental Health Assessment

Subject: Mental Health (Theory)

Overview

Mental Health Assessment include history taking in which we take history about different aspects like past illness history,family history of illness,personal history,health patterns.History taking is the collection of the subjective and objective detail data provided by the client himself or herself. It is the special techniques of the interviews. The main components of the history taking are pPatient’s bio-data ;Name,age/ sex,arital status,educational status,ccupation,address,socio-economic status,date and time of admission,hospital number,ward/unit,provisional diagnosis,chief complain,baseline data and so on.

Mental Health Assessment

History taking

History taking is the collection of the subjective and objective detail data provided by the client himself or herself. It is the special techniques of the interviews. During history taking the following preparation should be done:

  • Before interview
  1. Review of the available information like medical notes, administrative details, collateral history and referral letter.
  2. Ensure of the personal safety
  3. Find the appropriate room and are to conduct the interview
  4. Introduce yourself and explain the purpose of the interview.
  • Starting the interview
  1. Firstly introduce yourself in detail. Explain and inform about the purpose of the interview.
  2. Create the good interpersonal relation environment
  3. Inform about the timing of the interview
  4. Maintain the confidentiality during interview
  5. Note out the importance one during an interview.

Components of the history taking:

  1. Patient’s bio-data

Name-

Age/ sex-

Marital status-

Educational status-

Occupation-

Address-

Socio-economic status-

Date and time of admission-

Hospital number-

Ward/unit-

Bed number-

Doctor’s name-

Source of referral-

Provisional diagnosis-

 

  1. Chief complain
  2. Baseline data
  • Weight
  • Height
  • Abdominal girth
  • Vital signs:
  1. Temperature
  2. Pulse
  3. Respiration
  4. Blood pressure
  5. Details of admission
  6. Drug and alcohol/tobacco/cigarette history
  7. Leisure activities/ recreational activities
  8. History of present illness

> Onset (time, duration, gradual/sudden/any precipitating factors)

> Course of illness (progressive/episode)

> Sleep

> Appetite

> Loss of weight

> Libido

> Personal care

> Personality changes

 

  1. Past illness history

> Diabetes

> Hypertension

> Trauma

> Surgery

>History of mental illness- when, how long, treatment

 

  1. Family history of illness

> Family tree

> Health status

> History of mental illness

 

  1. Personal history

> Birth

  1. Complication during pregnancy
  2. Birth weight
  3. Any complications during birth

> Developmental milestones

  1. Motor
  2. Immunization
  3. Psychosocial

> Schooling

  1. Age when started
  2. Performance
  3. Relationships with peers
  4. Relationships with teachers

> Psychosexual history

  1. Masturbation
  2. Guilt feelings about homosexual/heterosexual relationships
  3. Extra marital relationship

> Menstrual history

  1. Age of menarche
  2. Regular/irregular

c.Duration of pain

  1. Quantity

e.Last menstrual period

 

> Work record

  1. Date/duration
  2. Performance in job
  3. Frequent change in job
  4. Job satisfaction

 

  1. Pre- morbid personality traits

 

> Mood

  1. Optimistic/pessimistic/anxious
  2. Hobbies/interest
  3. Use of alcohol/tobacco

 

  1. Health patterns

> Hygiene

> Eating habits

> Rest and sleep

> Elimination
Things to remember
  • Mental Health Assessment include history taking in which we take history about different aspects like  past illness history,family history of illness,personal history,health patterns.
  • History taking is the collection of the subjective and objective detail data provided by the client himself or herself.
  • It is the special techniques of the interviews.
  • The main components of the history taking are Patient’s bio-data ;Name,age/ sex,arital status,educational status,ccupation,address,socio-economic status,date and time of admission,hospital number,ward/unit,provisional diagnosis,chief complain,baseline data and so on.
Questions and Answers

During history taking the following preparation should be done:

  • Before interview
  1. Review of the available information like medical notes, administrative details, collateral history and referral letter.
  2. Ensure of the personal safety
  3. Find the appropriate room and are to conduct the interview
  4. Introduce yourself and explain the purpose of the interview.
  • Starting the interview
  1. Firstly introduce yourself in detail. Explain and inform about the purpose of the interview.
  2. Create the good interpersonal relation environment
  3. Inform about the timing of the interview
  4. Maintain the confidentiality during interview
  5. Note out the importance one during an interview.

History Taking

The process of taking a client's history involves gathering both subjective and objective detail information from the client. It is the unique interviewing methods.

Components of the history taking:

  • Patient’s bio-data
    • Name
    • Age/ sex
    • Marital status
    • Educational status
    • Occupation
    • Address
    • Socio-economic status
    • Date and time of admission
    • Hospital number
    • Ward/unit
    • Bed number
    • Doctor’s name
    • Source of Referral

Provisional Diagnosis:

  • Chief complain
  • Baseline data
    • Weight
    • Height
    • Abdominal girth
    • Vital signs:
  • Temperature
  • Pulse
  • Respiration
  • Blood pressure
  • Details of admission
  • Drug and alcohol/tobacco/cigarette history
  • Leisure activities/ recreational activities
  • History of present illness
  • Onset (time, duration, gradual/sudden/any precipitating factors)
  • Course of illness (progressive/episode)
  • Sleep,
  • Appetite,
  • Loss of weight,
  • Libido,
  • Personal care,
  • Personality changes,
  • Past illness history.
    • Diabetes,
    • Hypertension,
    • Trauma,
    • Surgery.
  • History of mental illness- when, how long, treatment.
  • Family history of illness
    • Family tree,
    • Health status,
    • History of mental illness.
  • Personal history
    • Birth
      • Complication during pregnancy,
      • Birth weight,
      • Any complications during birth.
  • Developmental milestones
    • Motor,
    • Immunization,
    • Psychosocial.
  • Schooling
    • Age when started,
    • Performance,
    • Relationships with peers,
    • Relationships with teachers.
  • Psychosexual history
    • Masturbation.
    • Guilt feelings about homosexual/heterosexual relationships.
    • Extra marital relationship.
  • Menstrual history.
    • Age of menarche.
    • Regular/irregular.
  • Duration of pain.
  • Quantity.
  • Last menstrual period.
  • Work record
    • Date/duration,
    • Performance in job,
    • Frequent change in job,
    • Job satisfaction,
  • Pre- morbid personality traits.
  • Mood
    • Optimistic/pessimistic/anxious,
    • Hobbies/interest,
    • Use of alcohol/tobacco.
  • Health patterns
    • Hygiene,
    • Eating habits,
    • Rest and sleep,
    • Elimination.

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