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Assessment Data
I did this based on a movie, so make up your own assessment
data?
Date:
Patients Initials:
JN
Positive Outcomes
The positive outcome we
are looking for is that the
patient will continue or restart taking his
medications, and learn how
to deal with the side effects
of his medications.
Antecedents
Experiences
delusional
episodes
Paranoid
Surrounding
environmental
factors
Patient Goal
Patient will start taking
medication, and will learn how
to cope with side effects of
meds and reports a decrease
3. Ineffective
Negative
Coping
Outcomes
(Complications)
Consequences
Psychological/Env
ironmental
stressors
Intervention
s
1. Impaired Social
Interaction
Interrelated Concept:
Interrupted Family
Process: Interpersonal
Relationships
1.Attend parenting classes
2.Attend couple's
counseling
3.Provide a support system
a. Have patient
attend group therapy
sessions
b. Have patient
participate in other
activities that he likes
c. Teach patient
ways to overcome his
impaired social
Patient Education
1. Teach patient about his
medications he is currently
on
2.Teach patient side effects
of his medications
3.Teach him the importance
of his medication compliance
and how to remember to
take them
4. Teach patient how to cope
with the diagnosis and how
to cope with hallucinations
Diagram Instructions:
2. Psychologist or Psychiatrist
3. Family Intervention
4. Possible social worker
a. Provide a
support system for
patient, and allow
him to express
himself
b. Assess patient
for risks of self-harm
c. Have patient
attend group
therapy where he
can learn to cope
and where he won't
4. Disturbed Sensory
Perception
a. Assess patient
frequently for
hallucinations and
delusions
b. When assessing patient
and he claims he sees
things, don't make him feel
like he is wrong
c. Encourage medication
compliance and teach
patient how to avoid non
compliance
5. Hopelessness
a. Encourage wife,
and family to visit
patient.
b. Encourage
patient to express
his feelings to you
and other staff
when feeling
hopeless or down
c. have patient
participate in
alternate activities
that he likes in order
to promote a
healthy and safe
environment where
he can enjoy an