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Exam 3 - Assessment (Indications of commonly abused drugs (CNS depressants…
Exam 3 - Assessment
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Sources of information
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friends, relatives, teachers, employers, etc.
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Priorities
Client's immediate concern/presenting problem #
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Assessment vs Diagnosis
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Diagnosis
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There are positives - identifies tx options, names condition, facilitates research
Negatives - self-fulfilling prophecies, stigma
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Tips for assessment
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Note supporting facts for your determination/conclusion of presenting problem, etc.
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Written assessment
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Be precise, accurate & legible
Avoid using labels, subjective terminology or jargon
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Include ct name, date, signature, credentials, etc.
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Assessment Components
Biophysical functioning
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Recent illness, medications, etc.
Risk of Aggression
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Physical conditions (head trauma, intoxication)
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Motivation
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Stages of change
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Determination (committed to action, develops plans for change)
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