Article: This is an expansive written interpretation of the information collected and how all of the elements recorded contribute to the patient's presenting problem. Recognize that every component of the patient's history is significant and will impact the patient's treatment, from the patient's chief complaint to the patient's family history. Include current symptoms and behavior. Include a description of the onset of the presenting problem, its duration and intensity. Look for non-verbal clues from the client such as an inability to make eye contact and nervousness. Observe and note the patient's hygiene, cleanliness, choice of clothing, behavior, mood and physical abnormalities. Include birth, childhood, family history and social relationships. Describe the patient's family history and current relationships. Indicate the patient's medical history and current status. Example "Jim is HIV positive and has been for three years, with a T-cell count within the normal range." Address a wide-ranging list contributing factors from the patient's support system to education and employment. Note the patient's strengths and weaknesses. Does the patient seem willing to work on the presenting problems? Will the patient work with a support system in place? Does the patient have medical issues or financial problems that might prevent them from completing treatment? Provide detailed information that offers an assessment of the risk factors as determined by information gathered during the interview. Examples of risk factors: Suicidal, homicidal, homelessness, trauma, neglect, abuse, domestic violence. This will include thought content (obsessive, hallucinations, delusions), affect, mood and orientation. Your comments and descriptions will be required. Example: Behavior: "Appropriate," "Inappropriate," and follow with a description of the behavior. In this section of the assessment, you will need to describe the patient's impairments. The categories include health,daily activities, social relationships and living arrangements. They'll require detailed descriptions if selected.
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Complete a narrative summary of your findings. Describe the patient's presenting mental health problem. Assess the patient's psychosocial history. Assess risk factors for the patient. Complete the Mental Status Exam checking all boxes that apply. Complete the Medical Necessity Criteria.