The Mini-Mental State Exam

Patient______________________________Examiner ___________________________ Date___________ Maximum 5 5 3 Score ( ) ( ) ( ) Orientation What is the (year) (season) (date) (day) (month)? Where are we (state) (country) (town) (hospital) (oor)? Registration Name 3 objects: 1 second to say each. Then ask the patient all 3 after you have said them. Give 1 point for each correct answer. Then repeat them until he/she learns all 3. Count trials and record. Trials ___________ Attention and Calculation Serial 7s. 1 point for each correct answer. Stop after 5 answers. Alternatively spell world backward. Recall Ask for the 3 objects repeated above. Give 1 point for each correct answer. ( ) ( ) ( ) ( ) ( ) ( ) Language Name a pencil and watch. Repeat the following No ifs, ands, or buts Follow a 3-stage command: Take a paper in your hand, fold it in half, and put it on the oor. Read and obey the following: CLOSE YOUR EYES Write a sentence. Copy the design shown.

( )

( )

2 1 3 1 1 1

_____ Total Score ASSESS level of consciousness along a continuum ____________ Alert Drowsy Stupor Coma

1. Intentional Self-Harm Individual factors: - expressing suicidal intent - clear plan - available means preparations - hopelessness - no confidant, e.g. partner, friends, professionals - poor coping resources - lack of blocks to selfharm Consider risk factors: -past history of deliberate self-harm - (i) alcohol/drug abuse OR - (ii) diagnosis (e.g. depression, schizophrenia, personality disorder) - (i) AND (ii) = increased risk - physical illness/disability - recent GP contact - recent psychiatric hospitalisation - recent loss - no friends/family - living alone - unskilled worker - unemployment - older people - male (especially young males)

2. Unintentional SelfHarm Consider selfneglect: - lack of self-care - not eating or drinking appropriately Consider unsafe behaviour: - not seeking help for problems posing risk - refusing appropriate help e.g. not taking medication - not claiming benefits - lack of awareness of own safety in home e.g. fire risk - risky sexual behaviour - substance misuse wandering Consider the inability to maintain a safe environment: - unable to manage accommodation - not paying rent - running up debts

3. Risk From Others Consider different types of abuse or exploitation: - physical - sexual - emotional - racial - financial - neglect Consider risk from: - staff - relatives - friends - neighbours - strangers - treatments Consider risk of abuse by carer: - severe stress - mental illness/alcohol /drug abuse in carer - carer refusing help - history of abuse by or to carer Consider risk from society: - history of abusive/exploitative relationships - harassment from public - use of home by unwanted others - inadequate home security - fear of retaliation for reporting abuse

4. Risk To Others Consider risk to: - children & other dependents - partners - carers - staff - neighbours - strangers Consider risk factors: - current threats, especially to a named person - history of violence to people/property - carers concern - access to weapons - no blocks to violence e.g. fear of consequences - history of arson - unemployment - drug/alcohol abuse - stress - voices telling person to harm someone - paranoia - risky sexual behaviour - anti-social behaviour e.g. unsafe driving - lack of information about persons history - no trusting relationship with professionals

5. Survival Consider whether the person has problems with: - a home - heating for the home - essential amenities (e.g. washing facilities, toilet, cooker, bed) - the ability to look after their home - the ability to keep adequately clean and tidy - enough food & fluids - clothing - enough money to live on - mobility - the ability to use public transport - the ability to cope with physical health problems

6. Psychological Consider: - overactive, aggressive, disruptive or agitated behaviour - problems with hallucinations & delusions - cognitive problems with memory, orientation & understanding - mood problems e.g. depressed, manic, anxious - problems with reading or writing - a lack of coping strategies - attitude to problems - help seeking behaviour - spiritual problems - feelings of alienation

7. Social Consider problems in relationships with others: - lack of ability to make or maintain friendships - lack of supportive relationships - lack of intimate relationship - sexual problems - communication problems - unable to handle daily hassles Consider problems in activities: - leisure - unpaid work - paid work - education - travel - lack of personally meaningful life

THRESHOLD ASSESSMENT GRID (TAG)

NONE
Domain 1 Intentional Self harm No concerns about risk of deliberate self-harm or suicide attempt

MILD
Minor concerns about risk of deliberate self-harm or suicide attempt

MODERATE
Definite indicators of risk of deliberate self-harm or suicide attempt

SEVERE
High risk to physical safety as a result of deliberate self-harm or suicide attempt

VERY SEVERE
Immediate risk to physical safety as a result of deliberate self-harm or suicide attempt physical safety as a

S A F E T Y

Domain 2 Unintentional Self harm

No concerns about unintentional risk to physical safety

Minor concerns about unintentional risk to physical safety

Definite indicators of unintentional risk to physical safety

High risk to physical safety as a result of self-neglect, unsafe behaviour or inability to maintain a safe environment Positive evidence of abuse or exploitation from other individuals or society High risk to physical safety of others as a result of dangerous behaviour

Domain 3 Risk from Others R I S K

No concerns about risk of abuse or exploitation from other individuals or society No concerns about risk to physical safety or property of others

Minor concerns about risk of abuse or exploitation from other individuals or society Antisocial behaviour

Definite risk of abuse or exploitation from other individuals or society Risk to property and/or minor risk to physical safety of others

Domain 4 Risk to Others

Immediate risk to physical safety of others as a result of dangerous behaviour

N E E D S & D I lS A B I L I T I E S

Domain 5 Survival

No concerns about basic amenities, resources or living skills

Minor concerns about basic amenities, resources or living skills

Marked lack of basic amenities, resources or living skills

Serious lack of basic amenities, resources or living skills

Life-threatening lack of basic amenities, resources or living skills

Domain 6 Psychologica

No disabling or distressing problems with thinking, feeling or behaviour No disabling problems with activities or in relationships with other people

Minor disabling or distressing problems with thinking, feeling or behaviour Minor disabling problems with activities or in relationships with other people

Disabling or distressing problems with thinking, feeling or behaviour Disabling problems with activities or in relationships with other people

Very disabling or distressing problems with thinking, feeling or behaviour Very disabling problems with activities or in relationships with other people

Domain 7 Social

TAG score 0 points for each None rating: 0 1 point for Each Mild rating: 2 points for each Moderate: 3 points for each Severe: 4 points for each V. Severe:

Camberwell Assessment of Need - Short Appraisal Schedule (CANSAS)

Client Name : . Registration No. : . Admission Date : Therapist Name :

Need Rating 0 = No problem 2 = Unmet need 1 = Met need 9 = Not known

Assessment number: Date of assessment: Who is being interviewed (U=User, S=Staff, C=Carer)? 1. Accommodation
What kind of place do you live in?

2. Food
Do you get enough to eat?

3. Looking after the home

Are you able to look after your home?

4. Self-care
Do you have problems keeping clean and tidy?

5. Daytime activities
How do you spend your day?

6. Physical Health
How well do you feel physically?

7. Psychotic symptoms
Do you ever hear voices or have problems with your thoughts?

8. Information on condition and treatment

Have you been given clear information about medication?

9. Psychological distress
Have you recently felt very sad or low?

10. Safety to self

Do you ever have thoughts of harming yourself?

11. Safety to others

Do you think you could be a danger to other peoples safety?

12. Alcohol
Does drinking or use of substance cause you any problems?

13. Drugs
Do you take any drugs that arent prescribed?

14. Social life

Are you happy with your social life?

15. Intimate relationships

Do you have a partner?

16. Sexual expression

How is your sex life?

17. Child care

Do you have any children under 18?

18. Education
Any difficulty in reading, writing or understanding English/Bahasa Malaysia?

19. Telephone
Do you known how to use a telephone?

20. Transport
How do you find using the bus, taxi, LRT or train?

21. Money
How do you find budgeting your money?

22. Benefits
Are you getting any financial assistance?

23. Spiritual
Do you have any specific belief and practices?

Met needs Count the number of 1s in the column Unmet need Count the number of 2s in the column Total number of needs A + B =

Functional Ability Assessment Rating Scale A) ACTIVITIES OF DAILY LIVING. I. Dressing 1. Independent in dressing. 2. Perform task, with prompting to begin. 3. Perform task, with intermittent prompting. 4. Perform task, with constant prompting. 5. Perform task, only with assistance. II. Eating a) Handling food 2. Difficulties in 1 area. 3. Difficulties in 2 areas. 4. Difficulties in 3 areas. 5. Difficulties in all areas. III. Grooming/Hygiene a) Face (shave/cosmetic) 2. Difficulties in 1 area. 3. Difficulties in 2 areas. 4. Difficulties in 3 areas. 5. Difficulties in all areas. IV. Domestic Skills a) Food Preparation d) Bed Making 2. Difficulties in 1 area. 3. Difficulties in 2 areas. 4. Difficulties in 3 areas. 5. Difficulties in 4 or 5 areas. b) Washing Dishes e)Laundry c) Housekeeping b) Hair c) Mouse d) Body 1. Independent in above areas. b) Use utensils c) Hygiene d) Chewing Food 1. Behavior in above areas is socially appropriate.

1. Independent in above areas.

V. Community Resources 1. Identifies and utilizes resources independently. 2. Identifies and utilizes resources with intermittent prompting. 3. Identifies and utilizes resources with constant prompting. 4. Identifies and utilizes resources with assistance and direction. 5. Does not identify and utilize resources. VI. Use of Community Facilities a) Shop d) Mail System b) Public Transport e) Public Toilet c) Phone

1. Utilizes resources independently. 2. Utilizes resources with intermittent prompting. 3. Utilizes resources with constant prompting. 4. Utilizes resources with assistance and direction. 5. Does not utilizes resources. VII. Time Management a) Leisure b) Work c) Rest 1. Able to balance time with lifestyle priorities. 2. Needs little prompting to establish priorities. 3. Needs some prompting to establish priorities. 4. Needs regular and constant prompting to establish priorities. 5. Has no concept of need to balance time with priorities. VIII. Money Management a) Recognizes money c) Use of banking facilities 1. Independent in above areas. 2. Some difficulties in 1 or 2 areas 3. Great difficulties in 1 or 2 areas 4. Great difficulties in more than 2 areas 5. Does not use skills in any areas b) Assesses correct change d) Budgets for lifestyle

B) TASK ORGANIZATION I. Attention Span 1. Attends to the task for more than 30 minutes. 2.Attends to the task for 20 30 minutes. 3. Attends to the task for 10 20 minutes. 4. Attends to the task for 3 10 minutes. 5. Attends to the task for 2 minutes. II. Problem Solving 1. Resolves problems independently. 2. Resolves problems after initial assistance. 3. Resolves problems with frequent assistance. 4. Identifies problems, does not resolve it. 5. Does not identify problem. III. Decision Making 1. Make decisions independently. 2. Make decisions and need intermittent assistance. 3. Make decisions, but need frequent assistance. 4. Only make decision if given 2 choices. 5. Does not make decisions. IV. Frustration Tolerance 1. Deals with complex and simple task independently. 2. Deals with simple task, become frustrated with complex tasks. 3. Deals with simple task with some frustration, becomes frustrated with more complex tasks. 4. Becomes easily frustrated with all tasks. 5. Does not perform tasks due to low frustration tolerance. V. Memory Functioning a) Immediate b) Long Term c) Sort Term 1. Independent functioning in above areas. 2. Intermittent recall of information. 3. Difficulties in 1 area. 4. Difficulties in 2 areas. 5. Does not recall information.

VI. Verbal Instructions 1. Follows all verbal instructions independently. 2. Follows three step verbal instructions. 3. Follows two step verbal instructions. 4. Follows one step verbal instruction. 5. Does not follow verbal instructions. VII. Learning Ability 1. Learns a simple and complex task without difficulties. 2. Learns a simple task, has intermittent difficulties learning a complex task. 3. Learns a simple, has frequent difficulties learning a complex task. 4. Learns a simple task occasionally, does not learn a complex task. 5. Does not learn a simple task.

B) PERSONAL/INTERPERSONAL ABILITIES I. Communication Skills a) Eye Contact d) Body Languages 2. Difficulties in 1 area. 3. Difficulties in 2 areas. 4. Difficulties in 3 areas. 5. Difficulties in all areas. II. Social Skills a) Sexual appropriateness c) Appropriate amount of verbalization 1. Independent in above areas. 2. Intermittent difficulties in 1 area. 3. Frequent difficulties in 1 or 2 areas. 4. Frequent difficulties in 3 or 4 areas. 5. Frequent difficulties in all areas. III. Passivity 1. Independent assertive functioning. 2. Passive less than half the time observed. 3. Passive about half the time. 4. Passive more than half the time observed. 5. Passive all the time observed. IV. Aggresion 1. Independent assertive functioning. 2. Communicates aggression in situations infrequently. 3. Communicates aggression in some situations. 4. Communicates aggression most situations. 5. Communicates aggression in all situations. b) Social Interaction d) Awareness of personal space b) Initiation e) Tones c) Listening

1. Independent in above areas.

V. Self Control (Ability to modify behavior for desired outcome) 1. Regulates behavior appropriately to all situations. 2. Regulates behavior appropriately to most situations. 3. Regulates behavior to some situation. 4. Regulates behavior appropriately to situations infrequently. 5. Never regulates behavior appropriately. VI. Self Concept a) Body Image c) Sexual Awareness 2. Difficulties in 1 area. 3. Difficulties in 2 areas. 4. Difficulties in 3 areas. 5. Difficulties in all areas. VII. Reality Orientation a) Time b) Place c) Person 1. Independent functioning in above areas. 2. Intermittent awareness. 3. Difficulties in 1 area. 4. Difficulties in 2 areas. 5. Difficulties in all areas. VIII. Managing Stress 1. Deals with major and minor stresses appropriately. 2. Can deal with minor stresses, occasionally not able to deal with major stresses. 3. Can deal with minor stresses, frequently not able to deal with major stresses. 4. Can occasionally to deal with minor stresses. 5. Unable to deal with minor or major stresses. IX. Initiative 1. Functioning allows independence. 2. Undertakes new tasks with initial prompting, but independent on routine tasks. 3. Undertakes new and routine task with intermittent prompting. 4. Undertakes routine tasks with constant prompting. 5. Does not undertake new task. b) Role Expectation d) Self Confidence

1. Functioning allows independence in above areas.

D) MOTOR TASK I. Balance a) Sitting b) Standing c) Walking 1. Balance allows independent functioning. 2. Utilizes assistive devices without difficulties. 3. Difficulties in one area without assistive devices. 4. Difficulties in two areas without assistive devices. 5. Difficulties in all areas without assistive devices. II. Coordination a) Gross motor 1. Intermittent. 2. Difficulties in one area. 3. Continuous difficulties in one area. 4. Difficulties in two areas. 5. Difficulties in all the above areas. b) Fine motor c) Visual motor

FUNCTIONAL ABILITY ASSESSMENT FORM User/Client name: Registration no.: Diagnosis: Address: Admission date: Marital Status: Therapist name: FAMILY HISTORY: WORK HISTORY: MEDICAL HISTORY / FACTS ON ADMISSION: SIGNS AND SYMPTOMS: MEDICATION / SIDE EFFECT: Ward: Gender: Age: Assessment date: No. of Admission: Occupation: Educational Level:

Start Date A. LIVING SKILL I Dressing II Eating III Grooming / Hygiene IV Domestic Skills V Community Resources VI Use of Community Facilities VII Time Management VIII Money Management Start Date B. TASK ORGANIZATION I Attention Span II Problem Solving III Decision Making IV Frustration Tolerance V Memory Functioning VI Verbal Instruction VII Learning Ability Start Date C. MOTOR TASK I Balance II Coordination Start Date D. PERSONAL / INTERPERSONAL ABILITIES I Communication Skills II Social Skills III Passivity IV Aggresion V Self Control VI Self Concept VII Reality Orientation
Scale 1-5 : Ratings E = Needs Further Evaluation NA = Not Assessed

Revie w1

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Review 4

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Review 4

Revie w1

Revie w 2

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Review 4

Revie w1

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Review 4

Other Abilities / Disabilities:

Signature : Name :. Date :.

Pt Code

Personal and Social Performance scale (PSP)

Date: ________________ Examiner: _________________ Marked Severe Very Severe

Assessment is based on the functioning over the last 1 month. Areas of functioning Absent Mild Manifest not marked a) Socially useful activities, including work and study b) Personal and social relationships c) Self-care d) Disturbing and aggressive behaviours Score 10-Point intervals 100 91 90 81 80 71 70 61 60 51 50 41 40 31 30 21 20 11 PSP Description

10 1

Excellent functioning in all four main areas. He/she is held in high consideration for his/her good qualities, copes adequately with life problems, is involved in a wide range of interests and activities Good functioning in all four main areas, presence of only common problems or difficulties Mild difficulties in 1 of areas a c Manifest, but not marked difficulties in 1 areas a c OR mild difficulties in d Marked difficulties in 1 of areas a c, OR manifest difficulties in d Marked difficulties in 2, OR severe difficulties in 1 of areas a c, with or without manifest difficulties in d Severe difficulties in 1 AND marked difficulties in 1 of areas a c, OR marked difficulties in d Severe difficulties in 2 of areas a c, OR severe difficulties in d, with or without impairment in areas a c Severe difficulties in all areas a d OR very severe in d with or without impairment in general areas a c. If the person reacts to external prompts the suggested score are 20 16; if not, the suggested scores are 15 11 Lack of autonomy in basic functioning with extreme behaviours but without survival risk (ratings 10 6) OR with survival risk, e.g. death due to malnutrition, dehydration, infections, inability to recognize situations of manifest danger (ratings 5 1)

Scoring Guideline Areas a c Absent Mild Manifest Guidelines Not manifest difficulties, known only to someone who is very familiar with the person Difficulties clearly noticeable by everyone, but not interfering substantially with the persons ability to perform his/her role in that area, given the persons socio-cultural context, age, sex, and educational level Difficulties interfering heavily with role performance in that area; however, the person is still able to do something without professional or social help, although inadequately and/or occasionally; if helped by someone, he/she may be able to reach the previous level of functioning Difficulties that make the person unable to perform any role in that area, if not professionally helped, or lead the person to a destructive role; however, there are no survival risks Impairments and difficulties of such intensity to endanger the persons survival (doesnt include suicidal rumination that does not cause a social dysfunction) Guidelines Absent Mild rudeness, unsociability or whingeing Speaking too loudly, over-familiarity in speaking, or eating in a socially unacceptable manner Insulting others in public, breaking or wrecking objects, acting frequently in a socially inappropriate but not dangerous way (e.g. stripping or urinating in public) Frequent verbal threats or frequent physical assaults, without intention or possibility to cause severe injuries Frequent aggressive acts, aimed at or likely to cause severe injuries

Marked

Severe Very Severe

Area d Absent Mild Manifest Marked Severe Very Severe