on suffering mental illness; a summary of the findings and concise note using the subjective, objective, assessment, and plan (SOAP) format with each patients encountered findings. The essay also provides some examples to support the findings.
First, Psychiatric history: this refers to the mental profile of the patient. It involves critical information about the patient’s chief complaint, their present illness, any psychological ailments they have made before or in the onset as well as after the mental illness (Hughes, & Kleespies, 2002). In this stage, more specific and closed ended questions could be asked during the assessment process so that the details of the patient’s illness or rather their profiles can be obtained. For instance, a patient who responds that, “I am just depressed.” Can be engaged further in questing through asking leading questions like, how long has the depression been? How often has the situation been? Or how long has this taken? Questions as such enable an in-depth understanding of the patient thus enabling a good history assessment of the mentally ill patient.
Secondly: medical history of the patient. This is medically understood as the patient’s past and evens the present and future that may communicate information relevant for their future, present and past health (Hughes, & Kleespies, 2002). It is an account of all the medical problems and events that an individual has experienced. It also includes other medical facts and treatments or injuries that an individual has been through. As much as possible, they are taken in the patient’s own words. The drugs taken, past and present hobbies use of alcoholics as well as an exhaustive survey of any symptoms that may not have been covered in the patient. This medical history is an important part of the health assessment of a patient with mental illness.
The 41 year old woman complaining of restlessness, little need for sleep, racing thoughts, inability to concentrate, alcohol ...
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