ADN PMH Assessment Guide
Content
University of Arkansas – Fort Smith
Student: Date:
Assessment Guide
Instructions: Complete the assessment guide on the day of assessment. No Blanks! May use N/A for not applicable. Star (*) significant data in red.
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Presenting Problem (What led the client to seek treatment? History of the current problem onset, symptoms, severity,
duration):
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Axis I: Axis II: Axis III: Axis IV: Axis V:
Brief Definition of Admitting Diagnosis (look up when you get home):
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Currently Ordered Medications:
Drug Dose and Route
Home Medications:
Frequency Drug
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> General Description (one paragraph, objective in nature):
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
PHYSICAL
Integumentary (general appearance of skin):
Sensory Neurological (seizures, headaches, etc) Cardiovascular Respiratory B/P _____________ P ____________ (rhythm _________)
R _________
Gastrointestinal (GI) Usual Diet/Favorite foods Ordered Diet Food Allergies Dental Health Nutritional Status IBW __________________ Recent loss/gain Genitourinary (GU) /Reproductive Sexual Dysfunction Urinary Elimination Pattern Bowel Elimination Pattern Musculoskeletal (muscle tone/strength, motor ability, tremors, etc) Last BM GI Complaints Current Weight ______________
Significant Lab Findings:
(Lab tests used to monitor therapeutic blood levels of Depakote, Lithium, anticonvulsants, etc;
WBC with Clozaril, liver studies on alcoholics, tests to rule out thyroid disorder, etc.) Date Lab Test Results Significance
Alcohol, Tobacco, Caffeine, OTC Drugs, Street Drugs
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> SAFETY AND SECURITY
Motor Activity
Speech Patterns
Emotions
General Attitude
Thought Processes
Violent Ideation (self or others)
If yes, evaluate plan and available means
Perception
Sensorium and Cognitive Ability Orientation
Memory
Impulse Control
Judgment and Insight
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> LOVE AND BELONGING
Developmental Level (Erickson): (Circle Developmental Task Achieved) Stage of Family Development (Duvall): Family Dynamics (significant family relationships) /Support Systems (significant others): Significant others (spouse, children, friends)
Who is the most important person in your life? Are people available to you when you are in need? Who/what provides you with strength and hope?
Productivity/Contribution (role contributions and responsibilities):
Currently Employed?
Health Beliefs and Practices (personal responsibility for health; special self-care practices)
Living Situation (living arrangements, type of neighborhood, etc)
Significant Losses/Changes (include approximate date and note how this affects behavior) {Stage of Grief: N/A denial anger bargaining depression acceptance}
Anxiety Level Ego Defense Mechanisms (describe how used by client)
Pattern of Coping with Stressors—Describe behavior when feeling: Anxious
Sad
Angry
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Self Esteem/Self Actualization
Level of Self-Esteem (circle one) Things client likes about self low moderate high
Things client would have liked to change about self
Objective Assessment of Self-Esteem: Eye Contact Posture Grooming/Hygiene
Dress Expressed Feelings of Inferiority Willingness to Initiate Conversation Participation (group activities, interactions with staff/other clients, etc)
Charting Day 1:
Charting Day 2:
Student: Date:
Assessment Guide
Instructions: Complete the assessment guide on the day of assessment. No Blanks! May use N/A for not applicable. Star (*) significant data in red.
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Presenting Problem (What led the client to seek treatment? History of the current problem onset, symptoms, severity,
duration):
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Axis I: Axis II: Axis III: Axis IV: Axis V:
Brief Definition of Admitting Diagnosis (look up when you get home):
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Currently Ordered Medications:
Drug Dose and Route
Home Medications:
Frequency Drug
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> General Description (one paragraph, objective in nature):
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
PHYSICAL
Integumentary (general appearance of skin):
Sensory Neurological (seizures, headaches, etc) Cardiovascular Respiratory B/P _____________ P ____________ (rhythm _________)
R _________
Gastrointestinal (GI) Usual Diet/Favorite foods Ordered Diet Food Allergies Dental Health Nutritional Status IBW __________________ Recent loss/gain Genitourinary (GU) /Reproductive Sexual Dysfunction Urinary Elimination Pattern Bowel Elimination Pattern Musculoskeletal (muscle tone/strength, motor ability, tremors, etc) Last BM GI Complaints Current Weight ______________
Significant Lab Findings:
(Lab tests used to monitor therapeutic blood levels of Depakote, Lithium, anticonvulsants, etc;
WBC with Clozaril, liver studies on alcoholics, tests to rule out thyroid disorder, etc.) Date Lab Test Results Significance
Alcohol, Tobacco, Caffeine, OTC Drugs, Street Drugs
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> SAFETY AND SECURITY
Motor Activity
Speech Patterns
Emotions
General Attitude
Thought Processes
Violent Ideation (self or others)
If yes, evaluate plan and available means
Perception
Sensorium and Cognitive Ability Orientation
Memory
Impulse Control
Judgment and Insight
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> LOVE AND BELONGING
Developmental Level (Erickson): (Circle Developmental Task Achieved) Stage of Family Development (Duvall): Family Dynamics (significant family relationships) /Support Systems (significant others): Significant others (spouse, children, friends)
Who is the most important person in your life? Are people available to you when you are in need? Who/what provides you with strength and hope?
Productivity/Contribution (role contributions and responsibilities):
Currently Employed?
Health Beliefs and Practices (personal responsibility for health; special self-care practices)
Living Situation (living arrangements, type of neighborhood, etc)
Significant Losses/Changes (include approximate date and note how this affects behavior) {Stage of Grief: N/A denial anger bargaining depression acceptance}
Anxiety Level Ego Defense Mechanisms (describe how used by client)
Pattern of Coping with Stressors—Describe behavior when feeling: Anxious
Sad
Angry
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Self Esteem/Self Actualization
Level of Self-Esteem (circle one) Things client likes about self low moderate high
Things client would have liked to change about self
Objective Assessment of Self-Esteem: Eye Contact Posture Grooming/Hygiene
Dress Expressed Feelings of Inferiority Willingness to Initiate Conversation Participation (group activities, interactions with staff/other clients, etc)
Charting Day 1:
Charting Day 2:
