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Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.
The assessment includes social and biographical information, direct observations, and data from specific psychological tests. It is typically carried out by a psychiatrist , but it can be a multi-disciplinary process involving nurses , psychologists , occupational therapist , social workers , and licensed professional counselors .
The mental status examination (MSE) is an important part of the clinical assessment process in neurological and psychiatric practice. It is a structured way of observing and describing a patient's psychological functioning at a given point in time, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and ...
Diagnostic and Statistical Manual of Mental Disorders (DSM) Chinese Classification of Mental Disorders; Feighner Criteria; Research Diagnostic Criteria (RDC), 1970s-era criteria that served as a basis for DSM-III; Research Domain Criteria (RDoC), an ongoing framework being developed by the National Institute of Mental Health
Mental health informatics is a branch of health or clinical informatics focused on the use of information technology (IT) and information to improve mental health. Like health informatics, mental health informatics is a multidisciplinary field that promotes care delivery, research and education [1] as well as the technology and methodologies required to implement it.
A clinical formulation, also known as case formulation and problem formulation, is a theoretically-based explanation or conceptualisation of the information obtained from a clinical assessment. It offers a hypothesis about the cause and nature of the presenting problems and is considered an adjunct or alternative approach to the more ...
The test was originally designed to measure aggression in psychiatric inpatients, specifically those with autism and other intellectual disabilities. [3] The scale is generally used to track aggression and aggressive acts over time, typically at one week intervals. [2]
A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician ...