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Rationale & Procedures: Conducting a Mental Status Examination

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Mental Status Examinations are used in many settings to determine if there are any conditions that are would prevent a client/patient from participating in their own care. A Mental Status Examination can help an intake worker to determine the level of care that would be most appropriate for the client. More importantly, it can reveal details that eliminate or suggest certain diagnoses. A mental status examination can also be conducted at any point in treatment to determine if the client is improving or getting worse. The format of mental status examinations ranges from a few brief questions to asking the subject to perform a series of cognitive tasks. Some examinations are done informally with brief documentation in a case note. Conversely, the results of a structured clinical interview might be reported in great detail. This solution introduces the components that most commonly assessed in a mental status examination and explains how the information is obtained.

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Solution Summary

Mental Status Examinations are used to determine a person's current level of mental functioning. Mental Status Examinations provide important infomation about the person's ability to participate in their care. This article expains how the basic components of a mental status examination are conducted. It is intended as an overview rather than as a set of instructions. New clinicians are advised to conduct Mental Status Examination under the supervison of a skilled clinician.

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A Mental Status Examination is an assessment of a person's current level and quality of mental functioning. The results of a Mental Status Examination can help in diagnosing a patient and determining the appropriate level of treatment. A common format usually includes the domains listed below. Sample questions are provided, but there are many formats. How the examination is conducted and documented varies among facilities and practitioners. A best practice is to document the person's exact verbal responses with the examiner's conclusion.

Observations

Appearance: Is the person dressed appropriately for the season and occasion? Are they clean and neat, or ...

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