Clinical Decision-Making & Case Analysis Flashcards
What are the first steps in assessing a new client? Establish rapport
gather history
What should you do if a client reports suicidal thoughts? Assess risk level (plan
means
How do you differentiate between crisis intervention and standard therapy? Crisis intervention is short-term
immediate stabilization; standard therapy is ongoing treatment.
What factors indicate a need for a higher level of care? Severe impairment in functioning
risk of harm to self/others
When should you refer a client for a psychiatric evaluation? If symptoms suggest severe mental illness requiring medication management.
How should you document a mental health assessment? Objective
detailed
What is the difference between structured and unstructured clinical interviews? Structured: Set questions
reliable. Unstructured: Flexible
When is it appropriate to use a mental status exam (MSE)? When assessing cognitive function
mood
How do you determine if a client’s symptoms are due to a medical condition? Review medical history
rule out substance effects
What are the key components of risk assessment in mental health? Suicidal/homicidal risk
substance use
What is a differential diagnosis
and why is it important? A process of ruling out conditions to ensure the most accurate diagnosis.
When should you conduct a substance use assessment? If there is concern about substance-related impairment in functioning.
What factors should be considered when forming a treatment plan? Client goals
symptom severity
How do you determine if therapy is effective for a client? Monitor symptom changes
client feedback
What is the best way to handle resistance in therapy? Explore underlying fears
use motivational interviewing
