The mental status exam is the primary examination used to evaluate and document a person's mental and emotional status at a specific point in their lives. This helps occupational therapists gather information related to the clients occupational performance and overall well-being. It helps occupational therapists look at appearance and behavior, speech, mood & affect, language and thought, perception, cognitive functioning, impulse control, insight and judgement and motor activity. The resource above on the left is the actual mental status exam that would be used during assessment. The resource on the right is from Brown University and gives a general description of what it is and how it can be beneficial. Making sure the experience is client-centered is important to maintain the occupational therapy practice as taking a holistic approach.
Person first language should be used when dealing with a client with schizophrenia
Identity-first language should be used when dealing with an autistic client.
Avoid stigmatizing language such as crazy, insane and abnormal
Avoid labeling people as their diagnosis such as anorexics or manic-depressives.
Identifying their life roles
Client's concerns and expressed goals, interests and attitudes
Precautions and safety concerns
History of self-injuries, suicidal thoughts or aggression towards others
Any involvement of family, caregivers, friends and significant others
desired outcomes (what their end goal is)
Brown, C., Stoffel, V. C., & Munoz, J. (2019). Occupational therapy in mental health: A vision for participation
(2nd ed.). F.A. Davis.