Mental Health Status Examination and SOAP

1
Mental Health Status Examination and SOAP

• From Assessment to Treatment
• By
• William A. Lambos
• and
• Shane Walters

2
Overview and Terms

• Agency clients, regardless of the referral source
  or reason, must be properly assessed before they
  can be treated.
• Following effective assessment, a treatment plan
  that addresses the needs identified in the
  assessment must be defined.
• During the course of treatment, the clients
  progress must be documented this is often done
  using the SOAP notes method.

3
Methods of Assessment

• There are several ways in which a new client may
  be assessed
• Clinical Interview
• Psychometric Testing
• Impresionistic Testing
• Behavioral Analysis

4
Clinical Interview and MSE

• Clinical Interview
• Handout 1 Biospsychosocial History

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Clinical Interview and MSE (Contd.)

• The Psychosocial Interview is often driven by or
  based on a form, which is intended to provide the
  interview with structure and uniformity across
  clients assessed by the agency.
• The areas addressed are those described in
  Handout 1.

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Clinical Interview and MSE (Contd.)

• The form often then has a section which
  incorporates the Mental Status Examination (MSE)
  and often DSM Axis IV-TR codes or diagnoses
• Axis I are the major diagnostic categories.
• Axis II are additional diagnostic categories
  which are considered secondary to the Axis I
  categories.
• Axis III is medical and is not assessed by
  counselors.
• Axis IV covers environmental and psychosocial
  stressors.
• Axis V is GAF, a scale of 1 to 100 of Global
  Assessment of Functioning.

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Mental Status Examination I

• The MSE covers
• Appearance
• Behavior and Psychomotor Activity
• Attitude Toward Examiner
• Speech
• Orientation and Consciousness
• Mood and Affect
• Perceptual
• Thinking
• Concentration and Attention
• Memory
• Demonstrated Defenses
• Insight into Difficulties
• See Handout 2

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Mental Status Examination II

• Appearance
• Dress (neat, disheveled, unkempt)
• Grooming Hygiene
• Behavior and Psychomotor Activity
• Gestures
• Twitches
• Restlessness
• Agitation
• Stupor
• Attitude Toward Examiner
• Cooperative
• Friendly
• Playful
• Guarded/Defensive
• Suspicious/Hostile
• Open/Frank
• Speech
• Minimal (mostly "yes" and "no" answers, little
  volunteered information)
• Talkative

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Mental Status Examination III

• Orientation and Consciousness
• Time, Place and Person (sometimes called
  orientation x three)
• Delirium (clouding of consciousness)
• Dementia (global intellectual/mental decline
  without clouding of consciousness)
• Mood and Affect
• Sad, Angry, Depressed, Anxious
• Restricted (reduced), Blunted (greater
  reduction), Flat (absence or near absence of any
  affect)
• Appropriate/Inappropriate
• Labile
• Perceptual
• Hallucinations (Auditory, Visceral, Tactile,
  Visual)
• Depersonalization (self experienced as unreal)
• Derealization (environment experienced as unreal)
• Thinking
• Rapid, Blocking, Circumstantial/Tangential,
  Loosening of Associations
• Thought insertion or broadcasting
• Abstract/Concrete (Procedure Proverb
  interpretation)
• Delusions (Grandiose, Persecutory, Somatic)
• Judgment (impaired/unimpaired)

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Mental Status Examination IV

• Memory
• Amnesia
• Immediate Auditory Attention (as in remembering
  digits forward)
• Short-Term or Recent (last few hours, days)
• Recent Past Memory (last few weeks and months)
• Remote Past Memory (childhood and distant past)
• Demonstrated Defenses
• Repression, Denial, Reaction Formation,
  Projection, Rationalization, Displacement, etc.
• Insight into Difficulties
• None (there is no problem, denial of illness)
• Superficial (some minimum awareness of a
  difficulty but still using denial)
• Situational Focus (external factors are the
  problem)
• Intellectual (Intellectualization and
  rationalization without true emotional
  connection)
• True Insight (understanding situation with
  emotional impetus to master situation)
• A Mini-Mental Status Examination addresses only
  cognitive functioning. It is typically used to
  screen for dementia and to monitor its
  progression. The Biosocial (Psychosocial) History
  covers other areas such as presenting problems
  and stressors, current living situation, family
  of origin, education, arrests or incarcerations,
  past treatment history, drug and alcohol usage,
  etc. It may also include observations such as
  those noted above.

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Mental Status Exam (Contd.)

• Assessment form from Center for Rational Living
• A ten page form, shown in Handout 3

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Mini Mental Status Exam I

• The Mini-Mental Status exam, created by Folstein
  in 1975, is a shortened version of the Mental
  Status exam. It is a widely used method that
  allows clinicians to assess clients in a shorter
  period of time. The purpose of the exam is to
  address cognitive functioning. It is typically
  used to screen for dementia and to monitor its
  progression. It is also useful for screening
  specific mental disorders such as Alzheimer
  disease. Today, due to the availability of more
  effective treatments for these types of
  conditions, it is being used as a tool for
  evaluating treatment effect. Within the MMSE, it
  is important to have some questions on suicidal
  ideation. During the examination, it is
  important that the examiner does the following
• Ask open questions
• Allow the client to explain things in his/her own
  words, encouraging the client to elaborate and
  expand
• Avoid interruptions
• Avoid why questions
• Listen carefully and observe the client

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Mini Mental Status Exam II

• Mini-Mental State Examination (MMSE)
• Questionnaire Orientation (score 1 if correct)
• Name this hospital or building.
• What city are you in now?
• What year is it?
• What month is it?
• What is the date today?
• What state are you in?
• What county is this?
• What floor of the building are you on?
• What day of the week is it?
• What season of the year is it?
• Registration (score 1 for each object correctly
  repeated)
• Name three objects and have the patient repeat
  them. Score number repeated by the patient. Name
  the three objects several more times if needed
  for the patient to repeat correctly (record
  trials).

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Mini Mental Status Exam III

• Attention and calculation
• Subtract 7 from 100 in serial fashion to 65.
  Maximum score 5
• Recall (score 1 for each object recalled)
• Do you recall the three objects named before?
• Language tests
• Confrontation naming watch, pen 2
• Repetition "No ifs, ands, or buts" 1
• Comprehension Pick up the paper in your right
  hand, fold it in half, and set it on the floor
  3
• Read and perform the command "close your eyes"
  1
• Write any sentence (subject, verb, object) 1
• Construction
• Copy the design below 1
• Scoring
•     24-30 May indicate normal cognitive
  functioning
•     20-23 Mild cognitive impairment
•     10-19 Moderate cognitive impairment
•     0-9 Severe cognitive impairment

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Mental Status Exam Contd.

• Whats not on these forms?
• The counselors impression of the client, based
  on the counselors clinical experience and
  judgment.
• This includes factors such as
• Severity or degree of perceived disturbance.
• Evidence of personality disorder (Axis II).
• Whether the client is in crisis.
• Whether the client may be in danger of harming
  self or others.

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Progress Notes SOAP

• The term SOAP stands for
• Subjective A direct quote of what the client
  says, I.e. My husband doesnt listen to a thing
  I say.
• Objective What the therapist observed, I.e. The
  Client paced around the therapy room and began to
  cry.
• Assessment The current situation based on the
  judgment of the therapist, I.e. The patient is
  at increased risk of leaving treatment AMA
  (against medical advice).
• Plan A suggestion how to address the problem or
  situation, I.e. The therapist will meet with the
  client at 3PM Tuesday to discuss her concerns
  about his behavior at work last Thursday.

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SOAP Contd.

• Soap is widely accepted because of its
  standardization of records. It allows clear
  communication between all professionals involved.
  It provides an organized structure which guides
  the counselor through the process of helping a
  client with a problem. It is an ongoing
  assessment of client's progress and treatment
  interventions. It also allows for
  accountability.

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SOAP Contd.

• When using SOAP, it is important to do the
  following
• record immediately after each session
• start each new entry with date and time of
  session
• write legibly and neatly
• use proper spelling, grammar, and punctuation
• be brief and concise
• use an active voice
• include client behaviors that are notable i.e.
  loss of focus when telling a story
• include change in attitude/ demeanor
• use precise and descriptive terms
• document all contacts or attempted contacts
• use only black ink if notes are handwritten
• sign-off using legal signature, plus your title

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References

• Anderson, Donald. (1992). A case for standards of
  counseling practice. Journal of Counseling and
  Development, 71, 22-26.
• Cameron, S. Turtle-Song, 1. (2002). Learning to
  write case notes using the soap format. Journal
  of Counseling and Development, 80, 286-292.
• Cormier, Sherry Nurius, Paula S. (2003).
  Interviewing and Change Strategies for Helpers.
  Brooks/Cole-Thompson Learning Pacific Grove, CA.
  
• Drummond, Robert J. (2004). Appraisal Procedures
  for Counselors and Helping Professionals. Pearson
  Education, Inc. Upper Saddle River, NJ.
• Folstein, M.F., Folstein, S.E., McHugh, P.R.
  (1975). Mini-mental state a practical method for
  grading the cognitive states of patients for the
  clinician. Journal of Psychiatric Research, 12,
  189-198.
• MacCluskie, K.C. Ingersoll, L.E. (2001).
  Becoming a 21st century agency counselor. Canada
  Brooks/Cole
• Mitchell, R.W. (1991). The ACA legal series
  Documentation in counseling records Vol.2.
  Alexandria, VA American Counseling Association.
• Sadock, Benjamin J. Sadock, Virginia A. (2003).
  Synopsis of Psychiatry. Lippincott, Williams
  Wilkins Philadelphia, PA.
• Zimmerman, M. (1994). Interview guide for
  evaluating DSM-IV disorders and mental status
  examination. East Greenwich R.I. Psych Products
  Press