Nursing Mental Health Assessment Tool
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Create a mental health assessment documentation for patient on psychiatric unit or with behavioral health needs.

Assessment details:
- Setting: [inpatient psych/medical unit/ED]
- Diagnosis: [psychiatric diagnosis]
- Voluntary or involuntary: [admission type]
- Legal status: [if applicable]

MENTAL STATUS EXAMINATION

1. APPEARANCE
   - Grooming: [neat/disheveled/describe]
   - Eye contact: [appropriate/poor/avoids]
   - Psychomotor: [normal/agitated/retarded]
   - Posture: [relaxed/tense/describe]

2. BEHAVIOR
   - Cooperative: [yes/no]
   - Agitation level: [calm/mildly/moderately/severely]
   - Unusual behaviors: [describe or none]

3. SPEECH
   - Rate: [normal/rapid/slow]
   - Volume: [normal/loud/soft]
   - Clarity: [clear/slurred/pressured]

4. MOOD AND AFFECT
   - Patient-reported mood: [in quotes]
   - Observed affect: [appropriate/flat/labile/constricted]
   - Congruence: [mood matches affect: yes/no]

5. THOUGHT PROCESS
   - Organization: [logical/tangential/circumstantial/disorganized]
   - Thought content: [appropriate/rumination/obsessions]
   - Delusions: [absent/present — describe]
   - Hallucinations: [absent/present — type and content]

6. COGNITION
   - Orientation: [person/place/time/situation]
   - Memory: [intact/impaired]
   - Attention: [adequate/distracted]
   - Insight: [good/fair/poor]
   - Judgment: [good/fair/poor]

7. SAFETY ASSESSMENT
   - Suicidal ideation: [absent/passive/active]
   - If present: plan/means/intent: [assess]
   - Homicidal ideation: [absent/present]
   - Safety plan: [reviewed/created]
   - Contraband search: [completed]

Note: Always follow institutional policies for mental health documentation. Placeholder information only.

Source: https://promptzyo.com/prompt/nursing-mental-health-assessment-tool