Mental State Assessment

The health record is a collection of information about a patient’s past and present health. The primary purpose of the health record is to document the health history of the patient. It helps in patient care management and patient care support process. Moreover, record’s primary purpose is to get information for billing and reimbursement. The secondary purpose of the health record is to provide a legal record of care given and act as a source of data to support clinical audit, research, resource allocation, performance monitoring, epidemiology and service planning. Sometimes health information will be de-identified before it is used for these secondary

Records are kept to promote, provide and improve the care provided for patients. They are also used for audits and quality assurance carried out by the Care Quality Commission (CQC).

8. List the nursing implications and education needs for each of the following categories of medication related to heart failure: See Attached

Clinical Assessment=According to our book, the term Clinical assessment generally refers to applying assessment procedures to (a) diagnose a mental disorder, (b) develop a plan of intervention, (c)monitor progress in counseling, and (d) evaluate counseling outcome. (Drummond, 2010). Clinical assessment has been the method used when diagnosing and planning treatment for a patient. The first step is evaluating the individual in order to obtain information and figure out what is wrong. Counselors, conduct this assessment to develop and adhere a plan of intervention, monitor clients progress, and ensue all information are interpreted and understood.

Purpose of Policy: To ensure medical records are completed in a timely manner by physicians, ensuring a complete record is available for continued patient care.

The electronic health record is the electronic version of a patients’ medical chart (Centers for Medicare & Medicaid Services, 2012). The information included in the electronic health record is the patient’s demographics and clinical health information, medical history, list of health problems, progress notes, medications, vital signs, laboratory and radiology reports, and physician orders. The purpose of the electronic health record is to prevent medical errors and improve care delivery to provide a safer patient environment (McGonigle & Mastrian, 2015).

Another use for this is that it provides a record for any important facts, findings, and/or observations of the patient's medical history. Whether it be past or present illnesses, exams, tests, treatments, and outcomes of the treatment due to a condition as well as their family history. It will also ensure that they receive excellent quality care, in its entirety, during a standard office visit or procedure and recovery.

My client is a 25-year-old South Asian woman. She appears thin with long black hair and brown eyes. She is wearing dark pants, a long sleeved blue shirt with a multicoloured scarf. Her clothing is neat and appropriate to her environment. She is wearing makeup, appears clean and is well put together. The client answers direct questions but does not provide a lot of information. Patient is willing to provide more information when asked directly or prompted by the writer. The client’s rate of speech was slow at first but as the interview continued, became a normal rate. Her speech was clear; however spoke in a soft volume with a monotone voice. Her rhythm was smooth and her speech was not pressured. The client’s

A complete medical record should provide an accumulation of all diagnoses and treatment that effect the patient's overall health and continuity of care. Also, for healthcare providers and the facility, the medical record will provide the legal record of all examination findings, treatments, and test results.

2. Data in a health record assist the media by controlling access to personal patient records. It can also then utilize in electronic health records and other data systems. In addition, data can help hospitals monitor closely, to improve and to report the data based on health care quality as well as safety.

Kirbas et al. (2013) used SD-OCT images to analyze RNFL thickness in untreated AD patients without visual impairment, and compared the results with healthy controls. In addition, patients were also administered a Mini-Mental State Examination (MMSE) which served to ensure that the patients were in an early stage of AD. In this study all of the optic nerve quadrants were analyzed, but the only significant results were those for the superior quadrant (76 ± 6.7 mm vs 105 ± 4.8 mm; P = 0.001), as well as the overall average RNFL thickness (65 ± 6.2 mm vs 75 ± 3.8 mm; P = 0.001). Furthermore, there was no correlation between MMSE scores and OCT measurements. In brief, there was a noticeable decrease in the total RNFL thickness of AD patients

Tehila started the interview stating that she does not want either of her parents or stepmother to know what she says during her meeting.

In Mental Health practice, the assessment of a patient is a vital part of their treatment as it is required to be aware of their ailment before a treatment plan/course is made. Therefore, risk management is a practice that involves the assessment and engagement of an individual through standard assessment tools and approaches so as to devise a means to manage an individual’s risk behaviour(s). Assessment is essential when it comes to nursing practice, as it is a major key element of knowing what care is required as well as knowing if the right form of care is delivered successfully (Combst et al., 2013). The questions that usually come to mind will be how the assessment is carried out and how will the practitioners and clients react to the outcome of this assessment. The aim of this assignment is to critically analyse the assessment tools, models and approaches utilised in mental health practice. Furthermore, a consideration will be given to the limitations of the assessment practice such as the reliability of the assessment tools. To carry out this task, a fictitious individual will be used in this report. A number of possible ailment and presenting risk behaviours are listed then an eventual analytical procedure for the individual’s assessment will be explained.

Healthcare Records – These records involve data about everyone associated with Healthcare, ranging from payers to providers.

Mental status exam is the psychological equivalent of physical examination that gives the description of behavior and mental state of an individual. The objective observation of the examiner and subjective description of the patient are needed in this assessment.