Elements of a Comprehensive Assessment
Assessment
Purpose
Person
Responsible
Sources of Information
Timeframe
Psychiatric History,
Mental Status, &
Diagnosis
 Ensure accuracy of diagnosis.  Psychiatrist.
 Inform plans that will be made
with the person in recovery
for treatment.




Psychiatric History
Narrative
 Establish timeline of course of  Psychiatrist.
illness and treatment
response.
 Psychiatrist’s interview with
 Started at admission or first
person being treated.
interview the person has with
 Psychiatric/Social Functioning
the psychiatrist.
History Timeline.
 Completed within the first 30
days.
 Identify current medical
conditions and ensure proper
treatment, follow-up, and
support.
 Determine health risk factors.
 Determine medical history.
 Determine if there are
problems communicating
health concerns.
 Person being treated.
 Medical records.
Physical Health
 Registered
nurse.
Person receiving services.
Family.
Supporters.
Past treatment records
concerning onset,
precipitating events, course
and effect of illness.
 Past treatment and treatment
response.
 Risk behaviors.
 Current mental status.
 Within 30 days, psychiatrist
schedules time to meet with the
person.
 Findings presented at daily
meetings to the team leader
and individual treatment teams,
and at the first treatment
planning meeting.
 First interview within 72 hours
of admission.
 If the person is experiencing
problems concentrating or
needs time to get to know the
staff to discuss sensitive areas
(i.e. sexual issues) the
assessment may need to be
completed over 2 to 3
interviews.
 Presented at first treatment
planning meeting unless there
are immediate concerns, in
which case the nurse should
consult the team psychiatrist &
the team leader & present the
concerns at the daily meeting.
Elements of a Comprehensive Assessment
Assessment
Use of Drugs and
Alcohol
Social Development
and Functioning
Person
Responsible
Purpose
Sources of Information
Timeframe
 Determine if the person
 Substance use
currently has a substance use
specialist.
disorder.
 Determine if the person has a
history of substance abuse
treatment.
 Develop appropriate
treatment interventions to be
integrated into the
comprehensive treatment
plan.
 Establish chronology.
 Composite International
 Assessment begins at
Diagnostic Interview –
admission.
Substance Abuse Module
 It may take several interviews
(CIDI-SAM) or similar
to collect this information since
standardized instrument.
it is sensitive information and
 Info is obtained from
requires a sufficient level of
interviews or discussions with
rapport and trust between the
the person that are conducted
person in recovery and mental
in the person’s home or
health professional.
community setting(s).
 Presented at first treatment
 Information also collected in
planning unless there are
the Psychiatric History,
immediate concerns in which
Mental Status, and Diagnosis
case the substance abuse
Assessment and the Health
specialist should consult the
Assessment.
team leader, the psychiatrist,
 Records from past treatment
and the individual treatment
providers.
teams.
 Assess how illness has
interrupted or affected the
person’s social development.
 Information is gathered about:
▫ Childhood & early
attachments.
▫ Role in family of origin.
▫ Adolescent and young
adult social development.
▫ Culture and religious
beliefs.
▫ Leisure activity and
interests.
▫ Social skills.
▫ Involvement in the legal
System.
▫ Social and interpersonal
issues appropriate for
supportive therapy.
 Obtained from interview or
discussion conducted in the
person’s home or other
community setting(s).

Mental health
professional.
 Begins at admission.
Information may be gathered
over several meetings.
Completed within 30 days.
 Presented at daily meeting or
to team leader, or at the first
treatment planning meeting.
Elements of a Comprehensive Assessment
Assessment
Purpose
Person
Responsible
Sources of Information
Timeframe
Activities of Daily
Living (ADL)
 Person’s current ability to
 Mental health
meet basic needs.
professional.
 Adequacy and safety of the
person’s current living
situation.
 Current financial resources.
 Effect of symptoms on
person’s ability to maintain an
Independent living situation.
 Person’s individual
preferences.
 Level of assistance, support,
and resources the person
needs to reestablish and
maintain activities of daily
living.
 Interviews or discussions with  An initial ADL plan is
the person.
completed at admission to
 Assessment takes place in
identify all immediate services
the person’s home or other
the person may need (e.g.,
community setting(s).
assists with nourishment,
 Interviewer must pay special
circumventing eviction).
attention to the person’s
 Information may be gathered
preferences and serve as the
over several interviews.
person’s advocate to insure
Comprehensive ADL
activities of daily living and
assessment is completed
other services meet the
within 30 days.
person’s preferences.
 Presented at the daily meeting,
to the team leader and the
individual treatment teams, and
at the first treatment planning
meeting.
Education and
Employment
 How person is currently
 Employment
structuring his or her time.
specialist.
 Person’s current school or
employment status.
 Person’s past school and
work history (including military
service).
 Affect of symptoms on school
and employment.
 Person’s
vocational/educational
interests and preferences.
 Available supports for
employment (e.g.
transportation).
 Source of income.
 Education, military and
employment chronology.
 Information obtained from
interviews with the person in
recovery.
 School records.
 Past employers.
 The assessment may be
completed over several
meetings, leading to an
ongoing employment
counseling relationship
between the person and the
vocational specialist.
 Presented at daily meetings or
directly to the team leader,
team members working with
the person, and at first
treatment planning meeting.
Elements of a Comprehensive Assessment
Assessment
Family and
Relationships
Purpose
Person
Responsible
 Allows the team to define with  Mental health
the person the contact or
professional.
relationship ACT will have
with the family and significant
others.
 Obtain information from
person’s family and significant
others about the person’s
mental illness.
 Determine the family’s and
significant others’ level of
understanding regarding
mental illness.
 Learn family’s expectations of
ACT services.
Sources of Information
 Person being treated.
 Significant others or family
members.
Timeframe
 Begun during the initial meeting
with the person in recovery and
family or significant others
participating in admission.
 Completed within 30 days of
admission.
 Presented at first treatment
planning unless there are
immediate concerns in which
case the mental health
professional should consult the
team psychiatrist and team
leader.
Based on The PACT Model of Community-Based Treatment for Persons with Severe and Persistent Mental Illnesses: A Manual for PACT