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 client�s 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

5. Clinical Interview and MSE (Cont�d.) 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.

6. Clinical Interview and MSE (Cont�d.) 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.

7. 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

8. 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 Rapid/Pressured (as in possible hypomania or mania)

9. 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) Suicidal or homicidal thoughts Concentration and Attention Distractibility Procedures: Serial 7s and 3s, Digits Forwards and Backwards

10. 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.

11. Mental Status Exam (Cont�d.) Assessment form from Center for Rational Living: A ten page form, shown in Handout 3

12. 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

13. 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).

14. 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

15. Mental Status Exam Cont�d. What�s not on these forms? The counselor�s impression of the client, based on the counselor�s 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.

16. Progress Notes: SOAP The term SOAP stands for: Subjective: A direct quote of what the client says, I.e. �My husband doesn�t 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.�

17. SOAP Cont�d. 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.

18. SOAP Cont�d. 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

19. 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