Using The Theory Of Unpleasant Symptoms As A Guide, What Would You Look For In An Assessment Tool For Patient Symptoms?

Only behavioural health EMR improves compliance while decreasing documentation time.
Clinicians using the ICANotes Behavioral Health EHR have access to over 75 different electronic rating scales and assessment tools for adults and children. To ensure that all patient records are easily accessible and secure, these rating scales and behavioural health assessments are integrated with the patient’s mental health chart and treatment plans. Built-in electronic estimates for depression, anxiety, PTSD, mood disorders, substance abuse, and many other conditions are available, allowing clinicians to spend less time on paperwork and more time with patients.

We’ve included the most widely used public domain behavioural health rating scales and assessment tools, such as:

Adult Evaluations
Child Evaluations
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What exactly is Assessment Tools?
Assessment tools are resources designed to assist individuals in recognizing the need to see a doctor or for clinicians to use when consulting with a patient. These materials can be in either paper or digital form.

Assessment tools use a standardized questionnaire to determine an individual’s mental health and whether they pose a risk to themselves or others.

Download our list of free behavioural health assessment tools.

Understanding the Different Types of Behavioral Health Assessments and Screening Tools for Clinicians
The Goal of Mental and Behavioral Health Evaluations and Screenings
Mental and behavioural health assessments are helpful tools; however, how do they work, and what can they do for your practice?

What precisely is a Behavioral Health Assessment?
A behavioural health assessment is a series of questions, interviews, and mental and physical examinations used by clinicians to gain a better understanding of their patients. Behavioural health evaluations are not intended to provide comprehensive diagnoses. Instead, they lay the groundwork and frame your patient’s concerns. The use of behavioural health assessments benefits both children and adults.

Why are mental health evaluations necessary?
The data gathered by assessment tools provide valuable insight into patient health and serve as a starting point for diagnosis and treatment.

Standardized mental health assessment tools allow clinicians to understand better their patients’ struggles, concerns, habits, and behaviours. You can evaluate these symptoms, behaviours, and concerns using assessment tools and compile them to create a personalized profile of their case. Assessment tools enable you to form a broad picture of your patient’s overall health.

Mental health assessments also enable the patient and the clinician to set and track treatment goals.

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What Is Involved in a Mental Health Assessment?
What Is Involved in a Mental Health Assessment?
Each mental health assessment you conduct will be unique to your patient and their symptoms.

A typical mental health evaluation may include the following components:

General interviews allow you to take note of your patient’s mood and presentation. Inquiring about the patient’s symptoms and concerns, as well as their life situation and thought patterns, can help reveal early areas to focus on.
Physical exam: A physical exam may be required to help distinguish between symptoms caused by a mental disorder and symptoms caused by a physical illness. Please inquire about your patient’s personal and family medical history, as well as any medications they are currently using.
Some symptoms may necessitate the use of lab tests or scans. Blood or urine samples and MRI, EEG, or CT scans may be helpful when evaluating a patient.
Written or verbal tests: You may want to administer a quiz to help identify specific problems and particular test functions or assess a patient’s overall health.
By pinpointing symptoms and providing valuable data, mental and behavioural assessment tools can help assist and guide your reviews. When choosing an agency, keep the following factors in mind:

Reliability: Is the test reliable enough to produce consistent results?
Validity: Does the test have the ability to distinguish between patients who have a problem and those who do not?
Sensitivity: Does the test have the sensitivity to identify a problem accurately?
Specificity: Is the test specific enough to identify people who do not have a problem?
Choosing a test that meets the above criteria will help ensure that your results are as accurate and helpful as possible. When working with patients, disorder-specific assessments are valuable tools, but how do you know which areas to test for? Screening tools can serve as a starting point for identifying these risk areas.

10 Assessment Tool Examples
Professionals in Mental and Behavioral Health
Assessment tools can help patients — young, old, and in between — with various mental and behavioural health issues. The following are ten different types of mental health tools for adults and children, along with famous examples from each category.

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1. Anxiety
Anxiety assessment tools, such as those listed below, can assist in determining which type of anxiety is most closely associated with your patient’s symptoms, as well as the severity of those symptoms:

Anxiety Stress Scale (DASS)
Screener for Generalized Anxiety Disorder (GAD-7)
Anxiety Rating Scale Hamilton
Anxiety Scale of Zung
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2. Addiction
Several tools are available to treat all addictions, including drug, alcohol, and gambling addiction. Among the valuable addiction assessment tools are:

Index of Addiction Severity (ASI)
Addiction Monitor in Brief
Screening Test for Drug Abuse (DAST)
Alcohol Use Disorders Screening Test (AUDIT-C)
South Oaks Gambling Screen Evaluation
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3. Disorders of Mood
Because the symptoms of different mood disorders can be similar, assessment tools can be used to help determine which condition your patient most closely resembles. The Mood Disorder Questionnaire and the Bipolar Spectrum Diagnostic Scale, for example, could be used in conjunction to help determine whether your patient has bipolar disorder rather than borderline personality disorder or something similar.

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4. Depression
Each patient has a unique experience with depression symptoms. Depression screening tools can assist you in tailoring sessions or tests to your patient’s specific requirements. The Geriatric Depression Scale and the Zung Self-Rating Depression Scale are two depression assessment tools.

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5. Personality Issues
The Adult ADHD Self-Report Scale, a famous personality disorder tool, is used to assess the symptoms of adults who may have ADHD.

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6. Suicide
If a patient exhibits suicidal symptoms, assessment tools such as the Columbia Suicide Severity Rating Scale can help determine the severity of those tendencies.

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7. Trauma
Trauma is divided into several sub-categories. The Post-Traumatic Stress Disorder Checklist and the Kessler Psychological Distress Scale have commonly used tools for diagnosing concussion.

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8. Disorders of Eating
When dealing with cases of suspected anorexia, bulimia, or binge-eating disorder, the Eating Disorder Diagnosis Scale comes in handy.

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9. Behavioral
Behavioural health assessments are intended to provide a complete picture of the patient’s home life, mental health, daily activities, habits, and other factors. Data from these assessments can be used to supplement and interpret information from other tests. Here are a few examples of behavioural assessment tools:

Wahler’s Inventory of Self-Description
Activities of Daily Living
Parental Stress Index
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10. Children and Young People
Adults are not the only ones who can benefit from mental health assessment tools. Numerous screening tools are available to aid in diagnosing and treating children and adolescents. Here are some examples:

Children’s Anxiety and Depression Scale Revised (RCADS)
Children’s Traumatic Events Screening Inventory (TESI-C)
Questionnaire of Emotions and Feelings (MFQ)
PTSD Symptom Scale for Children
Teenage Problem-Solving Screening Instrument (POSIT)
Checklist of Pediatric Symptoms (PSC)
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What is a Mental Health Assessment?
A mental health assessment typically begins with a patient’s appointment with their primary care physician. The GP will perform physical examinations and other medical tests.

After ruling out physical Illness, they will refer the patient to a mental health specialist, who will complete a brief problem checklist and administer additional mental health assessment forms.

These assessments will be either formal and standardized or informal and non-standardized. They can be self-reported assessments completed by the patient or by a therapist.

The following are some examples of standard formats for mental health assessments:

Observation Observation Interview

Checklists for the Family Interview

Questionnaires and scales of evaluation

Aspects of Mental Health Evaluation
1. Observation

Observation can assist you in determining a patient’s condition. Please take note of your patient’s attitudes, expressions, words, and actions in various settings to gain a better understanding of their situation than what they communicate. Please pay close attention to your patient and observe them with a professional, neutral demeanour to get the most out of this tool.

2. Interview

Psychiatric interviews can help you build rapport with your patients while gathering information about their symptoms and experiences. Allow your patients to speak freely and direct their responses with open-ended questions. While asking questions, keep diagnostic reasoning in mind. To gain your patients’ trust, make them feel validated and understood. Allowing your patients to express their feelings and experiences can help you identify the factors causing their symptoms.

3. Interview with a Family

In some cases, you may interview a patient’s family members, mainly when working with young children. Family interviews can provide additional information about a patient’s condition and help the family understand what the patient is going through. Before involving family members, you should read the Health Insurance Portability and Accountability Act.

4. Checklists

Like many screening tools, assessment tools include checklists to provide insight into a patient’s mental health status. A focused list can be a quick and efficient way to expand your knowledge. The DSM-5 includes lists to help you identify and classify patient symptoms, but you should use them cautiously. Checklists do not consider all biological, psychological, sociological, and cultural variables that may exist in a patient’s life. On the other hand, checklists can be helpful tools in conjunction with other assessment methods.

5. Scales of evaluation

Rating scales provide numerical data and assist patients in distilling complex feelings and emotions into simple responses. They can be helpful when working with patients who have difficulty communicating about their Illness or as a general assessment tool to determine the severity of symptoms at any given time.

6. Standardized Tests/Questionnaire

Assessment questionnaires are similar to screening questionnaires because they provide more information about a specific illness and its severity. If screening test results indicate the possibility of particular disorders, a disorder-specific assessment can assist you in gathering additional data. The Global Mental Health Assessment Tool, which can screen and assess various mental health issues, is an example of a standardized assessment.

During these assessments, clinicians take note of a patient’s appearance, behaviour, attitude, mood, insight, cognition, and other characteristics. All of the data gathered from health assessments and tools can now be used to create a profile that provides a comprehensive picture of your patient’s mental and behavioural health.

Allow ICANotes EHR Software to take care of your assessment tools.
ICANotes is the only EHR system that thinks like a clinician. Our software is always HIPAA compliant and protects the privacy of your notes, including preventing record alteration or destruction.

ICANotes Behavioral Health EHR is suitable for any mental and behavioural setting, such as:

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To learn more about what ICANotes can do for your practice, contact us today or click here to request a free trial of our EHR system.

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ICANotes Comes With Assessment Tools

Adult Behavioral Health Assessment Tools
Children’s Behavioral Health Assessment Tools
What Is the Distinction Between a Screening and an Assessment Tool?
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is nearly 1,000 pages long and contains hundreds of potential disorders you may encounter in your facility. It would be illogical and time-consuming to administer detailed assessments for all possible problems, which is why clinicians use screening tools.

The primary distinctions between screening and assessment tools
Here are some critical distinctions between screening and assessment tools.

Screening tools detect specific problems: Usually presented in a checklist or questionnaire, screening tests may be more comprehensive than assessments. When working with a patient, clinicians typically use screening tools early on to help focus on potential disorders.
Assessment tools provide a comprehensive picture: Assessment tools are typically used to determine the presence of a specific disorder and its nature and severity. Clinicians frequently employ assessment tools to delve deeper into screening results. Assessment tools are available in a variety of formats and for a variety of topics.
Mental health screening and assessment tools are helpful because they assist clinicians in quickly and accurately diagnosing and treating patients. Understanding the various screening and assessment tools enables you to make an informed decision for each patient.

7 Different Types of Behavioral Healthcare Screening Tools
The appropriate screening tool is determined by your client’s level of self-awareness and visible symptoms. If your patient’s family medical history includes mental Illness, you may want to screen for those disorders.

The following are seven common types of screening tools to consider:

1. General
Sometimes, your patient may be unaware of the symptoms and disorders they are experiencing. The Kessler Psychological Distress Scale, Patient Stress Questionnaire, and My Mood Monitor checklist are general mental health screenings that look for early signs of mental health symptoms. These screenings may also be used by primary care doctors during routine checkups to refer at-risk patients to behavioural and cognitive health specialists.

2. Depression
If your patient is depressed or has a family history of depression, screenings such as the Patient Health Questionnaire (PHQ) can help provide a more definitive answer.

3. Use of drugs and alcohol
Drug and alcohol screenings may aid in the identification of harmful habits or addictions in patients. The World Health Organization’s Alcohol Use Disorders Identification Test, for example, looks for dangerous alcohol use. The Drug Abuse Screening Test and the Tobacco, Alcohol, Prescription Medication, and Other Substance Use Tests are two other common drug and alcohol screenings.

4. Bipolar Illness
Clinicians can use the Mood Disorder Questionnaire to help identify symptoms of bipolar disorder. Because bipolar disorders exist on a spectrum, the Bipolar Spectrum Diagnostic Scale may help determine where or if your patient registers.

5. Suicide Danger
You can use the Suicide Assessment Five-Step Evaluation and Triage, the Columbia-Suicide Severity Rating Scale, or Ask Suicide-Screening Questions to help determine if your patient is at risk for suicide. Screening for suicide risk is an essential preventive measure to promote your patient’s safety and reduce risk.

6. Anxiety Issues
Anxiety disorder screening can assist you in determining whether your patient has symptoms of GAD, OCD, panic disorder, PTSD, or social phobia. The Generalized Anxiety Disorder seven-item (GAD-7) scale, the Post-Traumatic Stress Disorder Checklist for DSM-5, and the Hamilton Anxiety Rating Scale are all functional anxiety screenings.

7. Trauma
You can use the Life Events Checklist for DSM-5 to screen for potentially traumatic events in your patient’s life. This tool looks for common causes of PTSD or severe distress.

Consult with your patient to determine which screenings may be required. After identifying areas of concern, you can use assessment tools to understand the depth and scope of individual problems.

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Screening Instruments for Various Ages
Mental health screening tools for people of various ages
Different age groups have other screening tool requirements. A young child, for example, may lack the vocabulary to describe their symptoms as fluently and accurately as an adult. They require a screening test to which they can respond.

Clinicians must consider how age affects patients’ ability to express their feelings and experiences when selecting screening tools. For various age groups, here are screening recommendations for depression and anxiety, two of the most common mental disorders.

Adolescents and Children

According to the Centers for Disease Control and Prevention, depression affects 3.2% of children aged 3 to 17. Depression increases the risk of substance abuse, suicide, poor academic performance, and poor health choices.

Despite the severity of depression, it frequently goes undiagnosed in young patients, partly because children and adolescents may have difficulty expressing their feelings. Teens, in particular, may suppress their feelings or seek help from friends rather than adults for depression or anxiety. Fortunately, screening tests assist physicians, and behavioural health professionals in detecting depression and anxiety early on, allowing treatment to begin.

The United States Preventive Services Task Force (USPSTF) advises primary care physicians to screen adolescents aged 12 to 18 for major depressive disorder if the clinician can ensure an accurate diagnosis and effective treatment. The PHQ-9 and the Patient Questionnaire for Adolescents — a slightly modified version of the PHQ-9 — are both practical and widely used screening tools for depression in adolescents. The Kutcher Adolescent Depression Scale can also screen for depression in patients aged 12 to 17.

Pediatricians, psychiatrists, and other health professionals may use the Pediatric Symptom Checklist, a brief questionnaire, to screen children aged 4 to 16 for depression and anxiety. Another method for screening for depression in children ages 7 to 17 is the Child Depression Inventory, a modified version of the Beck Depression Inventory. Parents can gather information to assist a young child in completing a screening test.

Anxiety is more common in childhood and adolescence than depression, with 7.1% of children aged 3 to 17 suffering from this condition. You could use the Spence Children’s Anxiety Scale for patients aged 2 to 12, the Screen for Child Anxiety-Related Disorder for patients aged 8 to 18, or the GAD-7 for adolescents to screen for anxiety.
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Adults

Every year, approximately 18% of the adult population suffers from anxiety disorders, and half of those diagnosed with anxiety also suffer from depression. Depression and anxiety can make it difficult to meet daily responsibilities, maintain relationships, and care for one’s health. Depression is the leading cause of disability worldwide, according to the World Health Organization.

Because of the prevalence and severity of depression in adulthood, the USPSTF and American Academy of Family Physicians recommend screening all adults over 18, regardless of risk factors, for depression. PHQs is the most commonly used adult depression screening tools. You could start with the PHQ-2 and then move on to the PHQ-9 or a clinical interview if depression is identified.

Pregnant and postpartum women should be screened for depression by their doctors. Postpartum depression can harm a child’s development as well as family relationships. All pregnant and postpartum women should be screened for depression, according to the USPSTF, the American College of Obstetricians, and the American Academy of Family Physicians. The PHQ-2, PHQ-9, Edinburgh Postnatal Depression Scale, and Postpartum Depression Screening Scale are all options.

Consider the GAD-7 or the Kessler Psychological Distress Scale to screen for anxiety in adults. Both of these tools were the most commonly validated for anxiety disorders, according to a review published in BMC Psychiatry.

Senior Citizens

Screening for depression and anxiety becomes more complex in elderly patients. Patients may have a chronic medical condition contributing to their mental disorders and symptoms. Clinicians must select an appropriate mental health screening tool if a patient has dementia.

Anxiety is common among older adults, affecting 10% to 20% of the population. Stress is frequently misdiagnosed in older adults because patients and doctors believe the condition is caused by a medical condition or a prescription medication. Older patients may also be more hesitant to discuss mood disorders with their doctor or believe their feelings are normal. Anxiety, if left untreated, can lead to physical health problems, cognitive dysfunction, and a lower quality of life.

Screening tools designed for older adults can assist them in receiving treatment. The Geriatric Depression Scale, which includes yes/no questions, can screen for depression in older adults, including those with cognitive impairment. The USPSTF recommends the Cornell Scale for Depression in Dementia for patients with dementia. Another helpful screening tool for depression in older patients is the PHQ-2.
Only behavioural health EMR improves compliance while decreasing documentation time.
Clinicians using the ICANotes Behavioral Health EHR have access to over 75 different electronic rating scales and assessment tools for adults and children. To ensure that all patient records are easily accessible and secure, these rating scales and behavioural health assessments are integrated with the patient’s mental health chart and treatment plans. Built-in electronic estimates for depression, anxiety, PTSD, mood disorders, substance abuse, and many other conditions are available, allowing clinicians to spend less time on paperwork and more time with patients.