Mental Status Exam

Mental Status Exam (MSE): includes the social worker's observations and sense of the client. MSE should also include how the worker's observations change over time

MSE should include the following areas

-Appearance (dress, hygiene)
-Behavior
-Speech and Language (rate, rhythm, prosody, flow, content, first language, pressured, slurred)
-Emotions
-Mood (overall mood over time)
-Affect (how the client presents currently)
-Thought Process and Content
-Some types of thought process: circumstantial, perseveration, associations, tangential, loose associations, flight of ideas, thought blocking, confabulation)
-Sensory Perceptions (Delusions, Hallucinations)
-Mental Capabilities (is the client oriented to time, place and person?)
-Attitude
-Insight/Judgment

Biopsychosocial Spiritual Assessment

The Biopsychosocial Spiritual (BPSS) Assessment offers a historical context for what the client presents with and assesses the client's history, strengths, and resources.

The BPSS should answer the question: "How do these four areas contribute to the client's current functioning?"

The BPSS should ask questions to address each of the following aspects in detail:
Biology: basic needs - the client's access to food, shelter, etc
Psychosocial: history, personality, self-concept, medication, diagnosis and treatment history
Social: support system (friends, family, social environment)
-may use genogram here
-use both open and close-ended questions
-knowledge of life stages and development are essential
Spiritual: sense of self, sense of meaning and purpose in life, religion and its context in client's life

ROPES method of identifying strengths: Resources, Options, Possibilities, Exceptions, and Solutions

other notes:
-when working with kids, ask assessment questions of both kids and their parents. also, be sure to know and express the intended role of the parent in therapy or treatment
-BPSS creates a context and could be used to create a diagnosis, but is much more thorough than a diagnosis