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11 Cards in this Set
- Front
- Back
Clinical Assessment
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Process Clinicians use to gather information about clients. Crucial for: Diagnosis, Formulation, Treatment Planning, Predictions
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Typical Assessment Process
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- Clinical Intake Interview
- Mental Status Examination |
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Two Aims of Clinical Interview
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- Gather Information
- Establish Therapeutic Relationship |
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Clinical Interview
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- Biographical Information (e.g. Name, Occupation)
- Referral Information (e.g. Self-Referred) - Presenting Problems (symptoms and typography [e.g. frequency]) - History of Presenting Problem (Onset etc.) - Medical History & Drug Use - Family History - Personal & Social History - Strengths, Resources & Needs (e.g. Support Systems) |
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Mental State Examination (MSE)
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Therapists observations and impressions of client's mental functioning at time of interview
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Categories of Mental State Examination (MSE)
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- Appearance (e.g. Grooming)
- Behaviour (e.g. Posture and Body Movements) - Mood and Affect - Speech (e.g. Fluency and Rate) - Perceptual Disturbance (e.g. Hallucinations) - Thought Process and Content (e.g. Tangentiality and Delusions) - Cognition (e.g. Alertness) - Insight and Judgement and Reliability |
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Mood
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Predominant mood subjectively experienced and reported by client
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Affect
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Expression of emotion as observed by others
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Holistic Assessment
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Movement away from but includes symptomatology. Encompasses: Biological, Psychological, Social, Cultural, Spiritual.
Recent Stressors, Formulation and Readiness to Change. |
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Formulation
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Explains processes that caused and maintained the problems
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7P Formulation
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Presentation
Pattern Predisposition (factors that make them vulnerable to later psychiatric disorder) Precipitation (trigger for initial onset/exacerbation of symptoms) Perpetuation (maintain) Potentials Prognosis |