Comprehensive Assessment and Care Planning
Assessment that drives the plan
Comprehensive assessment gathers subjective and objective data across biological, psychological, social, cultural, developmental, and spiritual domains. The mental status examination covers appearance and behavior, speech, mood and affect, thought process and content, perception, cognition, insight, and judgment. Suicide and violence risk assessment is ongoing, direct, and documented: ask about ideation, plan, intent, means, rehearsal, protective factors, and past attempts. Screening tools such as the PHQ-9, GAD-7, C-SSRS, AUDIT, or MoCA structure inquiry but do not diagnose; a score informs, it does not replace clinical judgment.
Always rule out medical and substance-related mimics - delirium, hypoglycemia, hypoxia, thyroid disease, infection, medication effects, withdrawal - especially with acute onset, fluctuating course, or in older adults. Collateral information, with consent and within privacy law, improves accuracy. Formulation integrates predisposing, precipitating, perpetuating, and protective factors and leads to a prioritized, measurable plan. Goals are client-centered, collaborative, culturally congruent, and SMART; immediate safety needs precede long-term rehabilitation. Reassess continuously, because risk and capacity change.
Traps: treating a screening cutoff as a diagnosis; omitting direct suicide inquiry for fear of "planting" the idea; accepting self-report without checking cognition or collateral; attributing all symptoms to a known psychiatric illness; and writing vague goals such as "client will feel better." Candidates should also remember developmental and cultural variation - a behavior may be normative in context - and that involuntary status does not remove the duty to assess and plan with the person.
Worked example. An older adult with new confusion after starting an anticholinergic is labeled "anxiety." Rule of thumb: new, fluctuating cognitive change equals delirium until proven otherwise; assess onset, attention, vitals, medications, and medical status before adjusting psychotropics.