Assessment in casework

The component of casework assessment are:-

1. History taking
2. Mental status examination
3. Psychological tests

Psychosocial assessment tool

Date: ______________ Client name: ______________ intake date:

______________
Intake status: ______________ Age: ______________ Gender: ______________
Primary Language (written, spoken):
__________________________________________________________________
Diagnoses:
Axis I:
__________________________________________________________________
Axis II:
__________________________________________________________________
Axis III:
__________________________________________________________________
Axis IV:
__________________________________________________________________
Axis V:
__________________________________________________________________

1. Reason for admission, primary problem-

a. Client’s perception (i.e., what the client states as reason for admission):
b. Perception of others (i.e., information from concerned others, health care
providers about reason for client’s admission):
2. Precipitating factors (e.g., recent stressors, medication noncompliance,
life events):
3. Predisposing (risk) factors, family history:
4. Treatment history:
5. Current medications (include dosage, frequency):
6. Substance use, dependence
(Include type, quantity, frequency, and compliance, e.g., “How often do you
drink alcohol?” “On average, how many drinks do you have?” “How often
do you drink to the point of intoxication?” “Do you drink alone or with
others?”):
7. Physiologic and self-care concerns
a. Medical problems:
b. Physical impairments, disabilities, prostheses:
c. Self-care abilities, deficits, personal hygiene:
d. Review of systems (include weight gain or loss, note if intentional or
unintentional):
e. Sleep (include pattern, amount, and quality):
f. Nutrition (include appetite, food intake, food preferences, or dietary
requirements):
8. Ethnicity/culture
a. Cultural and spiritual beliefs and practices:
b. Health beliefs and practices:
9. Appearance (dress, facial expression, posture, eye contact; dressed
appropriately for weather and occasion):
10.Motor behavior (e.g., agitated, fidgety, unable to sit, pacing, no
movement):
11.Speech (include quantity, e.g., poverty of speech or minimal verbalization,
one-word answers, hyper verbal, incessant talking; quality, e.g., poverty of
content, latent responses, circumstantial, tangential, nonsensical, clanging or
rhyming, perseveration, echolalia):
12.Mental status
a. Mood and affect (mood, e.g., labile or stable, depressed, anxious, serious,
paranoid, giddy, scared, angry; affect, e.g., broad range or restricted, flat,
blunted, silly, inappropriate):
b. Thought process, cognition (i.e., how the client thinks; e.g., logical,
organized, rational or fragmented, loose associations, flight of ideas,
thought blocking):
 c. Thought content (i.e., what the client thinks about; e.g., suicidal or
homicidal thoughts, delusions—paranoid, somatic, religious, grandiose,
ideas of reference):
d. Sensorium and intellectual processes (include orientation to person,
place, and time; confusion; recent and remote memory; concentration and
attention spans; auditory, visual, olfactory, gustatory, tactile, or command
hallucinations; fund of general knowledge; and concrete or abstract
thinking abilities, e.g., interpretation of proverbs):
e. Suicidal or homicidal ideation (include suicidal ideas, active, i.e.,
thinking of ways to kill self; or passive, wishing to be dead or never wake
up; plan for suicide; whom the client wishes to harm and why):
f. Judgment and insight—limited, poor, good, fair (e.g., ability to solve
problems or make sound decisions; can the client see the relationship
between own behavior and situation?):
13.Self-concept (how client perceives self; “How would you describe yourself
as a person?”):
14.Client strengths (as identified by client and as identified by nurse):
15.Living situation (include other persons living with client; house, apartment,
and group home):
16.Educational and work history (e.g., college, trade school, GED; current
and past employment, when; type of job or career; volunteer work; income):
17.Roles and relationships (Is the client fulfilling current roles? Are roles
satisfying? Whom does the client have relationships with? Are relationships
supportive, satisfying, close, estranged, antagonistic, and troubled? Does the
client lack relationships?):
18.Coping skills and defense mechanisms (effective and ineffective, e.g.,
relief behaviors, “What do you do to relax when you are upset or stressed?”
“How do you solve a problem—think about it, spend time alone, talk it over
with a friend?”):
19.Interests and hobbies (include what the client currently does and what the
client has done in the past, when stopped and why):
20.How the client spends a typical day (outside the hospital, when the client
is feeling good/well and when having problems or stressed):
21.Teaching needs:
a. Barriers to learning (e.g., language or literacy barrier, lack of
motivation/available energy, inability to concentrate/ pay attention, lack
of insight, defense mechanisms such as denial):
 b. Client’s expectations for care (e.g., “How can we help you?” “What
would you like to accomplish while in the hospital?”):
22.Priorities for nursing care:
Discharge planning (include what client needs to be successful in
community living, e.g., placement, case manager, financial or legal help,
transportation, socialization; what client needs to manage illness; what the
client needs to improve quality of life):

Signature………………………

Assessment: The practice tree

Risk assessment tree
The practice tree: casework intervention\
Practice tree: psychological intervention.