The Mental Status Exam

› Results of structured screening tools • Any screening tools that have been administered should be scored and the outcomes recorded. A copy of the completed

assessment tool should be included with the biopsychosocial-spiritual assessment › Mental status exam

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• The mental status exam evaluates the client’s current mental state. Mental status examination information is gathered from both client report and observations of the client during the initial assessment interview. Areas of assessment include (Royal Children’s Hospital Melbourne, n.d.; Norris et al., 2016) –Appearance: grooming, hygiene, appropriateness of clothing for the environment –Behavior: appropriateness of facial expressions for social situation; posture; level of arousal (e.g., calm, agitated);

psychomotor activity; tremors, tics, or involuntary movements –Affect: whether affect is blunt, restricted, or overly expansive, appropriateness of affect to the social situation, whether

mood or affect is stable or labile