Clinical Assessment Protocol

Clinical assessment protocols are standardized observations clinicians make to evaluate the presentation of a mental health client. Assessment protocols allow clinicians to compare patient presentation from session to session and evaluate any changes in condition.

Function

• Clinical assessment protocols or mental status exams provide standard categories that all clinicians observe and record in mental health patients. The function of these categories is to assess aspects of mental health and to gauge the development or decrease of symptoms over time.

Assessment Categories

• The clinical assessment is composed of several parts. The clinician looks at orientation to date and time, appearance, motor, speech, affect, attitude, thought process and content, perception, attention, insight, and whether the patient is suicidal or homicidal.

Time Frame

• The clinical assessment is often completed within the first session or appointment, but may be repeated or re-observed throughout the tenure of treatment to evaluate reduction or increase in symptomatology.