aper Requirements:
The Mental Status Exam paper will focus on the ethical
social work activity of completing a multi-dimensional assessment using the DSM-5-TR.
In addition to the Mental Status Exam (MSE), emphasis will be placed on ethical
considerations and respect for diversity and inclusion based on the context of
the client presented in the case scenario. Students will be expected to use
diagnostic criteria from the DSM-5-TR and additional supporting readings
to demonstrate knowledge applied to the case scenario.
This assignment should be based on an actual client with
whom the student has worked in professional or internship settings. If this is
not possible, please meet with the instructor to discuss alternatives. Students
are not to use themselves, a family member, or close personal contact as the
subject of this paper, due to professional, ethical expectations prohibiting
dual relationships.
Students will submit a Mental Status Exam final paper.
Papers must be 10–12 pages and utilize the APA 7th edition format for formatting
and references, including a title page, introduction, body of paper,
conclusion, reference page, 12-point Times New Roman font, and 1-inch margins
in your paper. The paper must be double-spaced.
Final papers will be submitted at the end of the 7th week
of class. Details on the assignment will be provided on a rubric posted on
Moodle and in the Mental Status Exam assignment. An optional draft review is
included in week/module 5 to receive feedback from the instructor.
Papers must include each of the elements below.
Present de-identified demographic characteristics
for your client. These include a name, age, race/ethnicity, sex, gender
identification, and sexual orientation, as well as any others that are
relevant to your case conceptualization.
Identify the presenting problem. Include any
existing diagnoses and a recent (approx. six weeks) behavioral and
emotional profile.
Describe the history of the problem. Include any
historical diagnoses and history of treatment, including inpatient/
residential, outpatient (individual, family, group), and psychiatric
medication, as well as responses to these forms of treatment.
Identify the client’s current living situation.
Identify characteristics of the situation that facilitate and hinder the
client’s functioning, if any.
Describe the client’s current level of functioning
in the following domains as relevant:
Work
School
Family
Social
Sleep
Appetite
Identify and assess any current or historical
suicidal or homicidal ideation or behavior.
Identify and describe any current or historical
evidence of psychosis – delusions or hallucinations.
Conduct a mental status examination and describe
the results as they align with the following domains:
Orientation (person, place, time)
Appearance
Behavior (you can refer to sections II and III if
relevant)
Speech
Mood
Affect
Thought Process (you can refer to section VII if
relevant)
Thought Content (you can refer to section VII if
relevant)
Cognition / Memory
Insight / Judgment
Attitude / Rapport
Identify any physical health needs, medical
intervention, and impact on the client’s functioning if relevant.
Identify any substance abuse history and treatment
history if relevant.
Describe any trauma history, trauma symptoms, and
impact the trauma history has on the client’s current functioning if
relevant.
Identify any relevant legal history/involvement,
including criminal justice involvement if relevant.
Identify any relevant academic history.
Briefly describe relevant considerations
pertaining to the client’s family of origin. Characteristics may include
the functioning of the client’s parents, attachment considerations,
client’s economic circumstances and residential mobility growing up, and
birth / developmental history.
Describe the client’s peer relationships, social
support, and any significant relationship history.
Diagnosis: Explain how the diagnosis was arrived
at; specify diagnostic criteria met and not met; identify alternative
diagnoses that were considered and explain why they were discarded;
describe characteristics of the client (e.g., age of onset) that align or
do not align with diagnostic features and associated features of this
diagnosis.
Reflection:
Discuss the relationship that you have (or, if
the client is based on a case scenario, the relationship that you believe
you would have) with this client. In what ways are you similar to and
different from this client? In what ways do you experience power and
authority in the clinical relationship, and in what ways does the client
experience these dynamics (Competency 2.b)?
What types of personal biases might you
experience when working with this client? How would you identify and
manage those biases (Competency 1.c)?
What social work value/values particularly
pertain to the way you might experience working with this client in a
clinical context? Explain (Competency 2.d, Competency 1.a).
What tools would you rely upon to support your
use of ethical decision-making in relation to this client? Give an
example of a scenario that could arise that would result in the need to
consider ethical decision-making in the clinical context (Competency 1.a,
Competency 1.b).
In what ways are you well-prepared to work with
this client, and what additional education or professional development
might you need to effectively serve this client? If you were in a
professional practice context, how would you prepare yourself to best
serve this client (Competency 1.e)?
In what ways would you be required to interact
with technology in your provision of services to this client? How would
you ensure that your use of technology is ethical and in keeping with
social work values (Competency 1.f)?
Address how diversity and difference related to
any personal characteristics, which could include race/ethnicity, gender
identity or orientation, religion, and others, have impacted identity
formation for this client.
Identify ways in which this client has
experienced oppression, discrimination, marginalization, or alienation in
their life and how those experiences have impacted the client’s
functioning.
NSAW website to explore competencies.
Code
of Ethics: English (socialworkers.org)
Mental Health Exam
Cheat Sheet Description
Mental
Status Exam Cheat Sheet – Free Resource Download (icanotes.com)