Class Documentation 1 – Mental Status Exam
This assignment is worth 10% of your final grade.
1. Write a brief mental status on the client. Make sure that it includes the following:
• Reason for referral/how referred, Chief complaint-describe the client’s problem(s)
• Physical Appearance; Client’s reactions to the social worker
• Mood & Affect; Use of eye contact
Speech/language (receptive and expressive)
• Thought processes and content (word usage, stream of thought, organized thinking, continuity of thought, evidence of hallucinations or delusions
• Perception; Attention; Orientation (to person, place & time); Memory (immediate, recent & remote)
Ego Functions & Other Information
• Judgment; Intelligence, information and abstraction; Insight about problem; Decision making; Self image
• Sleeping patterns; Eating patterns; Indication of suicidal or homicidal ideation or past attempts
2. Identify and articulate client’s strengths and vulnerabilities—make sure to include the client’s coping strategies that will reinforce and improve adaptation to life situations, circumstances and events.
3. Assess the client’s readiness for change—make sure you provide specific evidence here to indicate the readiness for change level.
Please remember to keep your writing objective, support what you are saying about the client with examples (“as evidenced by”) and write in the 3rdperson.
Mental Status Exam
? Excellent, clear and concise description of the areas of concern. (2 points)
? Good, adequate description of the mental status but missing one item. (1 point)
? Poor, unclear description of mental status or inadequate or missing two or more items. (0 points)
Strengths and Vulnerabilities
?Excellent, clear and comprehensive articulation of the client’s strengths and vulnerabilities. (2 points)
?Good, adequate discussion of strengths and vulnerabilities but missing one or two required items (1 point)
?Poor, unclear or missing significant information. (0 points)
Readiness for Change
?Excellent, clear and comprehensive discussion of client’s readiness for change. (2 points)
?Good, adequate description of client’s readiness for change but missing one important item. (1 point)
?Poor, unclear description of client’s readiness for change. (0 points)
? Excellent, writing reflects graduate level skills. (2 points)
? Good, adequate writing style with one problem. (1 point)
? Poor, unclear, incomplete sentences or idea, not graduate level work. (0 points)
? Excellent, used quotations, accurate observations and accurate problem identification. (2 points)
? Good, used limited quotations, unable to present accurate observations, unable to identify problems (1 point).
? Poor, not quotations, does not accurately describe observations or identify client problems (0 points)
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