Mental Health Nursing Evaluation Form: A Patient Assessment Guide
Nursing notes are essential for mental health nursing, and thus they should be included in mental health education for undergraduate nursing students. In clinical settings, It has been observed that fourth-year nursing students commonly omitted critical information from the assessment of mentally ill patients, neglecting their requirements as well as losing valuable learning opportunities. For this reason, an evaluation form has been created and implemented in order to optimise the student’s learning opportunities. The main objectives that motivated the design of this instrument were to support the nursing student’s learning process, promote a systematic record of the mental examination, and apply specific descriptors in the assessment of the patient’s mental state. This evaluation form was designed according to a systematic and standardized registration system, including the main areas that compose mental health assessment. This cost-effective tool has significantly facilitated the student’s learning and training in mental health nursing. During the five-year period in which this instrument has been applied, student records improved in quality, precision, as well as a positive opinion about it from students. Besides, this document has been recently used in the context of distance education and clinical simulation in mental health by assessing patients in simulated situations, with positive outcomes.
Tables
| Area | Main items |
|---|---|
| General description | Appearance and hygiene, habits, sleep pattern, support network |
| Behavioural description | Rapport with the examiner, psychomotor activity and behaviour, attitude towards the examiner, mechanisms for coping with stress |
| Language | Verbal communication, tone of voice, verbal response, understand ability of language, reliability of the story |
| Humour and affectivity | Mood, predominant emotion, alteration of affect, level of self-esteem |
| Perception disturbances | Psychotic symptoms (e.g. hallucinations, delusions) Disorders not associated with psychosis (e.g. hearing loss, visual difficulty) Content, structure and speed of thought |
| Thought processes | Content, structure and speed of thought |
| Sensory and cognition | State of consciousness, orientation, memory and impulse control |
| Judgment and reasoning | Degree of understanding of the consequences of their actions, awareness of mental illness |
Table 1: Main items per area, assessed by the evaluation form.
References
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Harrisson S (2016) Nursing Progress Notes in Psychiatry: Mental Health Archival Data. Sante Ment Que 41(2): 69- 82.
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Setsu S, Emiko U, Tomoko K, Akiko S, Michiko S (2001) Development of an assessment sheet for home care. Int J Nurs Pract 7(3): 140-145.
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Odutayo P, Olaogun A, Oluwatosin A, Ogunfowokan A (2013) Impact of an Educational Program on the Use of Standardized Nursing Languages for Nursing Documentation Among Public Health Nurses in Nigeria. Int J Nurs Knowl 24(2): 108-112.
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Capponi R (1987) Psychopathology and Psychiatric Semiology 1st(edn), Editorial Universitaria, Santiago, Chile.
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