Development of Health Assessment - Assignment Example

Case study Name University Question 1 The mental and development health assessment uses diagnostic and statistical manual of mental disorders to guide the understanding of the mental status of patients. Since there is no definitive tests for mental status diagnosis, a series of tests is carried out to ascertain the mental status of a patient. The tests include the following; 1. Mental status examination; in this test the mental health professional meets face to face with the patient and assess the mental status of the patient(T Skovholt, 2010). This assessment will involve examining Tim’s absence or presence of suicidal tendencies, and psychosis. Psychosis is the impairment of one thinking which involves the examination of Tim’s orientation with time, the level of activity, and Tim’s personal goals. 2. Psychiatric evaluation; this evaluation involves a more intensive face to face, and other background checks in order to evaluate Tim’s current development status, Tim’s problems and symptoms, health status, his history that includes personal and medical history and other matters that may arise that may affect his development examination(T Skovholt, 2010). 3. Psychological assessment, this involves the examination of the presence of a certain condition like Tim’s level of depression, anxiety and susceptibility to stress. This examination will examine Tim’s overall wellbeing and mental status(T Skovholt, 2010). The psychological evaluation will evaluate the child’s overall treatment plan. 4. Developmental evaluation, this process will involve the examination of Tim’s level of understanding of cognitive, self-help, coping, emotional abilities, and the interpersonal skills of Tim. 5. Substance abuse examination, this will involve assessing Tim’s level of drug and alcohol abuse. This involves a comprehensive examination of Tim’s alcohol and drug abuse history. These tests are carried out in order to ascertain Tim’s level of diagnosis and mental and development status(T Skovholt, 2010). This process involves examination of Tim’s alcohol and drug abuse history and also using questions and substantive tests. Question 2 The two mental and developmental problems that Tim faces includes the following; 1. Depression; in Tim’s mental capacity he has demonstrated symptoms of depression which includes reduced concentration and attention levels, lack of motivation, social withdrawal, reduced drive, moodiness and irregular sleep patterns and the lack of energy. 2. Drug abuse, Tim’s history is full of drugs and substance abuse, although he was taken to a medical centre and diagnosed. He has not yet fully recovered from the effects of drug and substance abuse addiction. Question 3 Having no authority to gain aces to Tim’s medical history, I will have to consult with Tim’s previous doctors in order to obtain the appropriate documents. The process of consulting with other doctors require a procedure to be followed because a patient’s medical history is private and confidential. This will require me to produce proof that Tim is my patient and also in this case Tim’s consent. The law clearly provides that a heal care provider is required to supply a patient with his or her medical history upon request. In this case, if Tim, or his attorney, and any other representative in writing ask for his medical records to be transferred to another medical provider will be required to furnish me with the relevant medical documents except documents such as medical x-rays, lab reports, prescriptions and other technical information. Another medical institution is required by law to aid and facilitate the successful assessment and diagnosis of a patient. Question 4 The factors that have affected the appearance of Tim’s in the medical counselling process includes his level of depression, Tim’s high level of depression has caused him to withdraw socially and lack motivation to pursue his goals. His high levels of depression has caused his moodiness, irregular sleep patterns, lack of drive, motivation and direction to achieve his goals. This factors have affected Tim’s behavioural tendencies in the counselling process. His appearance is affected by his poor social skills, moodiness and lack of proper sleep. This factors usually impairs a person’s appearance making them look very awful. His history of drug and substance abuse plays a huge role in affecting the behaviour and appearance of Tim in the counselling process, the fear that people will ask him about his life is one of the large fundamental factors that has affected his development and behavioural process. Question 5 A counselling process is never directly suited to treat or diagnose a particular psychological problem. Counsellors have to carry out comprehensive tests in order to ascertain the best approach that will be used in handling a problem. In some cases, trial and error method is used to ascertain the best approach to use. In Tim’s case, the comprehensive assessment process that he will have gone through would be fundamental in coming up with the right method of treating him. This analysis will involve examining Tim’s medical history and previous diagnosis procedure, and identify their shortcomings, in order to be able to identify the best procedure to use in attending to Tim(T Skovholt, 2010). The best method in this case will encompass practical cognitive, behavioural and developmental techniques that will enable him overcome his high levels of depressions and learn to accept the shortcomings of his past life in order to be able to fully assimilate with the society. Much of Tim’s diagnosis will be based on improvement observations in order to examine his progress. The behavioural and humanistic approach will be suitable in handling his case. Question 6 The process of recognising and referring to potential serious problems, which Tim has in line with organisational requirements will be based on active counsellor listening and client speaking activities. During the counselling sessions, Tim will be required to speak about his life and his approach to life(T Skovholt, 2010). This would enable me to be able to highlight certain factors that might be bad for his organisational or work requirements. Other than active listening skills, me as a counsellor will utilize behavioural observation skills that will enable me highlight problems that will enable him have problems at work. His high levels of depression, secrecy, and anti-social skills are more likely to become detrimental in his work and life activity Question 7 The relationship between a counsellor and a patient is imperative in the diagnosis process. In order for-Tim to be able to fully express himself appropriately and develop a relationship with the counsellor; reciprocal trust will have to be cultivated. It is the responsibility of the counsellor to provide a safe, confidential setting for the client to be able to feel free to speak and develop trust with the counsellor. The operating environment should be filled with empathy, understanding and respect for the client. In order to cultivate the appropriate relationship my tonal voice, and the words that I use to communicate with Tim will affect the relationship that we will develop(T Skovholt, 2010). Offering Tim my thoughts and concern will enable me to develop the caring relationship with him, this relationship will become imperative in encouraging Tim to relax and talk freely. Allowing sufficient delays with Tim during the counselling process will enable Time to open up more freely. In order to maintain the relationship that has been established, I would use a sensitive approach in highlighting my problems, concerns and issues that need to be highlighted. The sensitiveness of my approach will encompass offering empathy, guidelines, and reassurance in order for him to become more comfortable. Like in any relationship, the counsellor and client relationship will have to establish boundaries. There will be existing clear demarcations as to where I can go, or the line I can cross, and also boundaries will be set to Tim. Question 8 In order to get a complete and comparative overview of Tim developmental and mental status, I will have to consult with close family and friends. This will enable me to gain a complete picture of Tim’s living, habitual, and relational situations both at home and in his work place(T Skovholt, 2010). Parents and friends will contain information that Tim would not have, and this information is necessary in creating the right diagnosis for Tim. The information the Tim would miss providing can be given by his parents, relative and friends. The gathering of information from them will be based on the need for Tim to become well. When the wellness factor of Tim is the objective, then I can be able to obtain as much information as I can get about Tim. Gathering of information about Tim from his family members and friends will be part of Tim’s assessment; it would help build hid proper diagnosis plan or plans. Question 9 The notes that I would keep including Tim’s session, case notes and progress notes. These notes are imperative for Tim’s diagnosis process. This notes will enable more to be able to monitors Tim’s progress effectively without compromising on the diagnosis process. This notes will serve as a guide against forgetfulness they will enable me to remember the things that will be covered in the sessions(T Skovholt, 2010). They also provide a god documentation that the session were carried out in highest standards, and in due regard of the ethical and professional standards that are required. In the case of referrals, the notes will serve as a case for referrals to other councillors. Most importantly this notes serve as a measure of assessment. Follow-up, and interventions. The sessions papers will cover each session, highlighting what was covered, progress, significant notes, and any assignment if any that was given. The progress notes will analyse the overall Tim’s progress this will cover the direction that the client is taking in handling his problems and tackling his issues. Progress notes enable me to be able to dictate the direction of counselling, and also evaluate the whole clients’ progress. The case notes will highlight how each Tim’s case is progressing and the intervention mechanisms used in handling that case. Notes and other documentation are imperative in shaping the direction of counselling and also in cases of accountability. It is vital for notes to be kept by any counsellor during his counselling sessions. Reference T Skovholt, M. T.-M. (2010). The resilient practitioner: Burnout prevention and self-care strategies for counselors, therapists, teachers, and health professionals. New York: Taylor & Francis. Read More