INTRODUCTION Mental health history information is gathered to create a succinct description of the client’s mental health. A completed history is usually only a few pages in length, although it contains a great deal of information. It is presented in a standard format that includes the following topics:
IDENTIFYING DATA Identifying data briefly summarize the case, including information about previous hospitalizations, reasons the client is seeking help at this time, and some indication of the current problem. An example of this element follows: This is one of numerous psychiatric admissions for this 45-year-old-woman, who is readmitted at this time for recurrence of paranoia, auditory hallucinations, and suicidal ideation. CHIEF COMPLAINT Chief complaints are direct quotes from the client, usually no more than a sentence, that describes the client’s perception of the current problem. An example of this element follows: "The voices are telling me to kill myself and I can’t get away from them." PRESENT ILLNESS HISTORY Present illness history is a description of the events leading up to this admission or to the client’s seeking help at this time. This section includes an identification of current stressors, the client’s perception of precipitating factors or events, response to previous treatment interventions if this is relevant, and the immediate symptoms causing the person to seek help. An example of this element follows: The client was discharged from the hospital 1 month ago. She attended a day treatment program but took her medication inconsistently. She states she was working on "abuse issues" in the day treatment program and she discovered her "frozen inner child." This discovery prompted further self-recriminations and the client became more preoccupied with suicide. The client has also recently discovered that her husband is having an affair. She blames herself because of her weight and wants to go on a crash diet, hoping to get him back. PAST MEDICAL HISTORY Past medical history is an outline of known medical conditions, including laboratory test results and other diagnostic information. DEVELOPMENTAL OR PSYCHOSOCIAL HISTORY Developmental or psychosocial history is an outline of life circumstances that are significant for understanding the current problems. An in-depth history includes information about:
An example of this element follows: The client is the middle child in a family with three children. Her parents had an intact marriage, although there was a great deal of overt and hidden hostility between them and with the children. The client feels she was the primary target because she is the only daughter. She has flashbacks of her mother and father yelling at each other in the night and of being abused physically and emotionally for minor infractions. The client denies any sexual abuse. Nursing Alert: Research has shown that there is a genetic predisposition, or familial pattern, in the occurrence of mental illness. A developmental history should screen for other family members with problems of this nature. PHYSICAL EXAMINATION A physical examination is always included as a component of the mental health evaluation. In a hospital setting, it is standard practice to complete this examination within 24 hours of admission. Frequently, if there are medical conditions, a specialist will be asked to consult on the case. Nursing Alert: Physical causes of behavioral problems must always be carefully assessed and ruled out before the focus of treatment can be exclusively psychiatric.
A mental status examination (MSE) evaluates the client’s current mental functioning. It involves a precise series of observations as well as some specific questions.
Psychiatric diagnosis is made according to the standards presented by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 4th edition, referred to as DSM-IV. Excerpted from Mabbett, P. D. (1996) Delmar’s Instant Nursing Assessment: Mental Health. Albany, NY: Delmar Publishers. |
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