Comprehensive Assessment Copy

Assessment should be thought of as an ongoing process in order to identify needs, strengths, and progress to inform treatment. Screening and an intake assessment is the first step to be performed. The purpose of the screening is to gather enough information to determine whether there is evidence of early psychosis or other mental health concerns. In addition this screening can assist in relieving distress, identifying cognitive impairments and setting the tone for a therapeutic relationship. If available, further examination by a psychiatrist may help confirm the clinical picture or offer alternative explanations for the presenting conditions. Engagement is a priority during these initial contacts with the client and family and other involved individuals.

When screening reveals the likely presence of psychosis, the clinician should then move on to do a more comprehensive biopsychosocial assessment. This assessment should involve other health care providers if possible – especially a psychiatrist and/or family physician. Consultation with a family physician is important at this initial stage to gain further knowledge of physical and medical history of the client. It is important to have readily available a professional in your community who is familiar with the use of medication and can prescribe medication.

Comprehensive biopsychosocial assessment is performed within the first several weeks of care and captures the following:

  • Detailed description of signs and symptoms
  • Mental status exam and cognitive screening
  • Comorbid conditions
  • Safety and risk
  • Personal and family history
  • Current stressors and methods of coping
  • Basic needs
  • Medical examinations, including body mass index
  • Client and family explanatory model
  • Functioning across roles and domains
  • Drug and alcohol use
  • Social support networks
  • Personal strengths and weaknesses
  • Client and family goals
  • Clinical formulation, preliminary diagnosis and care planning

This assessment must be informed by collateral sources including the family. At each subsequent visit, risk, mental status, medication side effects, new stressors and treatment progress are conducted at each visit.

There are templates for initial assessments and assessments updates available in the early psychosis care pathway. To review these tools, access the care pathway page by clicking on the care pathway icon.
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