FOR INFORMATION PURPOSES – NOT A CLINICAL DOCUMENT

ABSCATT Mental Status Assessment

AMH Procedure 01-01 Inpatient Observation Levels (2016)

A
Grooming/Dress Hygiene
Appearance
Level of consciousness Eye contact
Movement Gait/Posture
B Behaviour Motor activity
Social behaviour
Compulsions
Impulse control

S
Rate/Flow Volume
Speech
Quality Quantity
Orientation Attention
C Cognition Concentration
Judgment
Memory
Insight
Qualities Descriptors
A Affect/Mood Stability
Level of anxiety
Intensity/Range
Congruence
Organization Coherence
T
Thought Process/
Logic Stream
Perception Hallucinations/Illusions Feelings of unreality

T
Delusions Suicidal/Aggressive thoughts
Thought Content
Ruminations Obsessions

Suicide Risk Screening

AMH Procedure 02-01 Suicide Risk Screening, Assessment and Safety Planning (2016)

When conducting an initial assessment, responses are related to current or prior history. For follow-up
reassessments, responses are only related to the current situation or since the last assessment.

Question
Has the patient previously harmed or attempted to harm/kill themselves?

Does the patient wish they were dead, or could go to sleep and not wake up?

Does the patient have thoughts of harming themselves?

Has the patient participated in increased risky behavior involving the thought of causing death or self harm?
(e.g. excessive speeding, playing chicken with the train)

If this is a reassessment, move on to two questions below.

If this is an initial assessment:
- If Yes to any of the above questions, continue to Suicidal Ideation Assessment/Reassessment.
- If No to all of the above questions – skip Suicidal Ideation / Reassessment section and move onto
Current Primary / Risk Propensities.

Question
Have there been any recent changes to the patient’s mental status?

Have there been any recent changes to the patient’s treatment plan that would impact risk?

If Yes to any of the above questions, continue to Suicidal Ideation Assessment/Reassessment.

AHE – April 2016 Inpatient AMH Suicide Risk Management Policy Suite
 Mental State Assessment Charting Guide
General Observations Charting Descriptors
Appearance Level of Consciousness Alert/attentive Drowsy Unresponsive Fluctuating

Hygiene / Grooming Neat/clean Evidence of self neglect Attire

Nutritional / Physical Looks healthy Recent wt. loss/gain Under-weight Over-weight

Eye Contact Appropriate Stare Occasional glances No eye contact
Behaviour Physiologic Signs Flushed Pale Diaphoretic Respirations Heart rate

Calm Restless Sped up Slowed Odd/purposeless movements

Motor Activity Repetitive movements Tics Self abusive Frank agitation
Spastic/uncoordinated Catatonic-like posturing Ritualistic

Gait Slow Brisk Uncoordinated Shuffling Propulsive

Posture Relaxed/comfortable Rigid/erect Hunched/slouched Exaggerated
Cooperative Sarcastic Withdrawn Suspicious Evasive Oppositional
Attitude toward Domineering Overfamiliar Hostile Frightened Indifferent Cocky
Interviewer Submissive Intimidating
Social Behavior Appropriate Isolated Disinhibited Seductive Shy/awkward Aggressive
Impulse Control Acts with appropriate restraint Responds inappropriately to limits

Emotional State
Reactive Elated Anxious Angry Suspicious Dazed Fearful
Affect Incongruent Sad Irritable Restricted Expansive Flat Labile

Mood Client’s response to “How do you feel most days?”

Level of Anxiety Self rated as: None Mild Moderate Severe Near panic
Vegetative / Somatic Energy Appetite Libido Anhedonia Sleep: Initial insomnia
“Do you feel that life is not worth living?” “Are you thinking about suicide?”
Risk Suicidal Ideation Current Plan Access to lethal/harmful means
Homicidal Ideation /
Thoughts of harming other(s)? Who/how?
Intent
Cognitive Functions
Orientation Time Place Person Recognizes significant other
Attention/Concentration Good Impaired Easily distracted Short span of attention
Memory Immediate recall Recent Remote
Estimate of Intelligence Average Below average Above average
Insight Aware of illness/need for treatment Impaired

Judgment Able to problem solve Appropriate decisions Hasty, impulsive decisions

Thought Processes
Easy to follow/understand Slow Rapid Pressured
Speech Rate / Quantity Gives sufficient information Talks excessively 1 or 2 word answers Mute
Whispers Shouts Slurred Stutters Rhyming Lively
Quality / Flow Spontaneous Long pauses Halting Rambling Clear/coherent
Incoherent Overly vague Overly detailed Repetitive
Thoughts organized and logical Disorganized Lacks logical connections
Ideas Organization/Form Tells obvious lies Concrete Tangential Circumstantial

Thought Content
Hallucinations Auditory Visual Gustatory Tactile Olfactory

Delusions Nihilistic Depressive Grandiose Persecutory Bizarre

Delusions of Control
Ideas of Reference
Preoccupations
Obsessive Thoughts
Phobias
Controlled by other(s) Heard out loud by others
Able to control thoughts/actions of others
Believes radio/tv Conversations between others are about self
Returns to the same idea(s) constantly Ruminates about past events or feelings
Intrusive, unwanted, distressing or horrific, recurrent thoughts
Irrational fear of an object/situation leading to avoidance

AHE – April 2016 Inpatient AMH Suicide Risk Management Policy Suite