Assessment of Adults

OPTIMAL OUTCOME OF ASSESSMENT:

1. A working alliance with the client is initiated.

2. The client is assessed to be best served by the mental health organization and the client is connected with relevant treatment staff; or is facilitated to begin treatment at the agency deemed most appropriate. Immediate safety needs of the client are addressed.

3. Diagnosis is reached using DSM-IV criteria, and immediate treatment goals are negotiated.

4. Historical information and current level of functioning which define the context of the presenting problem is obtained.

5. Individualized treatment planning is initiated.

ASSESSMENT PRINCIPLES:

1. Assessments should be provided in a manner that is sensitive to cultural and individual differences.

2. Reasonable accommodations in keeping with the Americans With Disabilities Act (ADA) requirements should be made for clients with disabilities.

3. The client's description of the presenting problem initiates the assessment. Dealing with the client in an empathetic manner should take priority over information gathering.

4. Whenever an adult is seen who has a previous psychiatric diagnosis, the assessing clinician should re-evaluate the appropriateness of the diagnosis.

5. The context of the presenting symptoms should be gathered/obtained with special attention to the following:

• When were the symptoms noticed, and under what circumstances? (How long, how often, how severe?) To what degree are the symptoms impairing daily functioning?
• Are the psychiatric symptoms associated with physical symptoms?
• Are the symptoms associated with the use of substances, or are substances being used to self-medicate the symptoms? This is best assessed when history taking, and again when the working alliance is fully established.

6. The client's current living circumstance should be assessed including: housing, access to the necessities of living, family involvement, social support, current job status and employment.

7. Relationship history should be assessed, including the ability to establish and sustain satisfying relationships.

8. The Assessment should include (but is not limited to):

• family of origin and current family information
• physical symptoms and medical history, including medications and allergies
• impulses to harm self or others
• legal history
• history of personal and family psychiatric treatment
• patterns of personal and family alcohol/substance abuse
• history of traumatic experiences
• other personal history including developmental milestones and work history

9. The assessment should include a mental status exam. This exam may be formal or informal, may employ an instrument, or be integrated into the assessment process. The exam should assess for the existence of psychotic symptoms, affect disturbance, anxiety symptoms, and cognitive impairment.

10. Diagnoses should be achieved with adherence to DSM-IV criteria. Diagnoses should not be made in ways that are impressionistic or idiosyncratic. Full use should be made of diagnoses of co-morbid conditions, atypical presentations, V codes, and deferred and provisional diagnoses. Diagnoses should be made on all the DSM-IV Axes. Diagnoses given by previous clinicians should be reassessed for appropriateness and currency.

11. Assessment is an on-going process, therefore, working diagnoses may change and should be continuously evaluated and updated consistent with new information.

12. The Utah Scale for Serious and Persistent Mental Illness (SPMI) should be completed as part of the assessment.

THESE GUIDELINES HAVE BEEN DEVELOPED BY:
THE UTAH PREFERRED PRACTICE CONSENSUS PANEL
UNDER THE AUSPICES OF THE UTAH DIVISION OF MENTAL HEALTH

APPROVED MAY 9, 1997

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