Current Assessment

ASSESSMENT DETAILS

Date of assessment: [textarea cols=20 rows=1 default="date"]

Time of assessment: [textarea cols=20 rows=1 default="time"]

Communication issues: [textarea cols=50 rows=1 default="Nil communication issues"]  

Interpreter required: [textarea cols=20 rows=1 default="No"]

Sources of information: [textarea cols=80 rows=5 default="Patient; EMR Notes; Triage report (ACS)"]

Other people present: [textarea cols=40 rows=5 default="Mum, Dad, Caregiver"]

Location: [textarea cols=50 rows=1 default="Community Mental Health"]

Referred by: [textarea cols=50 rows=1 default="Name of referrer"]

Reason for referral: [textarea cols=80 rows=5 default="patient name was referred second to concerns over"]

HISTORY OF PRESENTING PROBLEM

History of presenting concerns: [textarea cols=80 rows=10 default="History of presenting concerns"]

Has assessment considered suicidal ideation, preparation or plans: [textarea cols=20 rows=1 default="Yes / No"]

Has assessment considered risk of harm to others: [textarea cols=20 rows=1 default="Yes / No"]

Current treatments:   

[textarea cols=80 rows=5 default="medications: nil"]
[textarea cols=80 rows=5 default="psychological: nil"]
[textarea cols=80 rows=5 default="complementary / alternative: nil"]
[textarea cols=80 rows=5 default="other services involved: nil"]

Current Physical Health problems:

[textarea cols=80 rows=10 default="details of physical health problems"]

Has assessment considered metabolic risks: [textarea cols=20 rows=1 default="Yes / No"]

Is the patient a smoker: [textarea cols=20 rows=1 default="Yes / No"]

Current recent substance use:
[checkbox value="None|Cannabis|Heroin|Prescription Pain medication|Stimulants|Hallucinogens|Cocaine|Alcohol|Tobacco|Caffeine"]
[textarea cols=80 rows=10 default="Patient denied substance use when asked"]

Current legal issues:
[textarea cols=80 rows=10 default="Patient denied legal issues when asked"]
Is the patient subject to any legal orders or sanctions: [textarea cols=20 rows=1 default="Yes / No"]

Current functioning and supports:

[textarea cols=80 rows=10 default="Living conditions are currently stable"]
[textarea cols=80 rows=10 default="Relationships are positive; Patient has social supports and denied any recent losses."]

When asked about approach-oriented coping strategies, the patient identified:
[checkbox value="meditation and relaxation|allowing time for self|physical activity|connecting with friends|trying to see the humourous side|hobbies|spirituality|pets|sleep hygiene|nutrition"] [textarea cols=40 rows=5 default="Nothing of note"]

When asked about avoidance-oriented coping strategies, the patient identified:
[checkbox value="drug use|alcohol use|self-harm|ignoring the problem|sedatives|stimulants|over-work|avoiding the problem|denial|over-sleeping"] [textarea cols=40 rows=5 default="Nothing of note"]

CURRENT PARENTAL/CARER STATUS

Is the patient pregnant or living  with someone who is pregnant: [textarea cols=20 rows=1 default="Yes / No"]

Is the patient in an active carer or parental role to dependents: [textarea cols=20 rows=1 default="Yes / No"]

MENTAL STATE EXAMINATION

Appearance: [select value="alert and oriented to time, place and person|OBTUNDED|DISORIENTED|HYPERALERT|-"],[select value="well kempt|POORLY KEMPT|appropriately dressed|INAPPROPRIATELY DRESSED|appropriately groomed|INAPPROPRIATELY GROOMED|DISHEVELED|-"],[select value="normal posture|SLUMPED|RIGID|TENSE|-"].[textarea cols="20" rows="2"]
Behavior: [select value="calm|RESTLESS|AGITATED|RETARDED|PECULIAR|IMPULSIVE|-"],[select value="interactive|WITHDRAWN|-"],[select value="eye contact good|eye contact AVOIDANT|eye contact INTENSE|eye contact FLEETING|-"]. [textarea cols="20" rows="2"]
Attitude: [select value="cooperative|HOSTILE|OVER FRIENDLY|SECRETIVE|EVASIVE|SUSPICIOUS|APATHETIC|EASILY DISTRACTED|FOCUSED|DEFENSIVE|DEMANDING|SEDUCTIVE|-"]. [textarea cols="20" rows="2"]
Speech: [select name="spontn" value="spontaneous|NON-SPONTANEOUS|MUTISM|-"],[select name="rt" value="N reaction time|INCR REACTION TIME|DECR REACTION TIME|VARIABLE|-"],[select name="rate" value="normal rate|SLOW|POVERTY|PAUCITY|RAPID|OVERTALKATIVE|PRESSURE|-"],[select name="vol" value="normal volume|LOUD|SOFT|WHISPHER|MONOTONE|-"],[select name="rhythm" value="clear rhythm|SLURRED|HESITANT|APHASIC|-"].[textarea cols="20" rows="2"]
Mood reported as: [textarea cols="20" rows="2"],inferred as-[select value="euthymic|NOT REPORTED|ANXIOUS|DEPRESSED|DYSPHORIC|IRRITABLE|ELEVATED|EXPANSIVE|ELATED|EUPHORIC|ANGRY|HOSTILE|INDIFFERENT|DETACHED|ANIMATED|-"]
Affect: quality: [select value="euthymic|ANXIOUS|DEPRESSED|DYSPHORIC|IRRITABLE|ELEVATED|EXPANSIVE|ELATED|EUPHORIC|ANGRY|HOSTILE|INDIFFERENT|DETACHED|ANIMATED|-"], [select value="range normal|BROAD|RESTRICTED|-"], [select value="intensity normal|EXPANSIVE|BLUNTED|FLAT|LABILE|-"], [select value="congruent|INCONGRUENT|-"] 
Thought form: [select value="coherent|INCOHERENT|CANNOT BE ASSESSED|NOT ENOUGH SAMPLE|-"],[select value="logical and goal directed|-|CIRCUMSTANTIAL|TANGENTIAL|LOOSENING|FLIGHTS OF IDEAS"].[select value="-|NEOLOGISM|BLOCKING|VERBAL PERSEVERATION"]. [textarea cols="20" rows="2"]
Thought content: [select value="no delusion on current evaluation|DELUSION PRESENT|CANNOT BE ASSESSED|-"],[select value="no active suicidal ideations at present| SUICIDAL IDEATIONS PRESENT|DEATH WISHES PRESENT|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="2"]
Perception: [select value="no hallucination on current evaluation|HALLUCINATION|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="2"]
Insight: [select value="present|PARTIAL|POOR|MOSTLY BLAMES OTHERS|DIFFICULTY IN ACKNOWLEDGING PRESENCE OF PSYCHIATRIC SYMPTOMS|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="2"]
Judgment: [select value="intact|IMPAIRED|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="2"]
Cognition: [select value="intact|ABNORMALITIES PRESENT|PENDING|CANNOT BE ASSESSED|-"]. [textarea default="normal attention, concentration, intact ability to recall recent and remote information, normal abstraction" cols="50" rows="3"]
Attitude to and engagement in care: [select value="positive|NEUTRAL|NEGATIVE|UNABLE TO RATE"]. [textarea cols="20" rows="2"]

DV SCREENING

[checkbox value="Yes, within the last year patient name reported being hit, slapped or hurt in other ways by their partner or ex-partner.|No, within the last year patient name denied being hit, slapped or hurt in other ways by their partner or ex-partner.|Yes, patient name is frightened of their partner or ex-partner.|No, patient name is not frightened of their partner or ex-partner."] 

DV ACTION TAKEN

[checkbox value="Domestic violence identified, information given.|Domestic violence identified, information refused.|Domestic violence not identified, information refused.|Support given and options discussed.|Reported to FACS.|Police notified.|Other violence/abuse disclosed."] 

[textarea cols=80 rows=5 default="DV - referrals made to: N/A"]

[textarea cols=80 rows=5 default="DV - other action taken: N/A"]

[textarea cols=80 rows=5 default="DV - other comments: N/A"]

INVESTIGATION AND RESULTS:

[textarea cols=80 rows=5 default="Pathology results: N/A"]

[textarea cols=80 rows=5 default="Radiology results: N/A"]

[textarea cols=80 rows=5 default="External testing: N/A"]

[textarea cols=80 rows=5 default="Metabolic monitoring: N/A"]

[textarea cols=80 rows=5 default="MH Outcome measures: see forms"]

FORMULATION

[textarea cols=80 rows=15 default="patient name presented to Community Mental Health with symptoms associated with (ICD-10 or diagnosis). These symptoms were precipitated by (precipitating event). Factors that predispose patient name to (presenting concern) might include (predisposing factors). The symptoms associated with (presenting concern) are likely being maintained by (maintaining factors). However, patient name's protective and positive factors include (protective factors)."]

DIAGNOSIS

[link url="http://apps.who.int/classifications/icd10/browse/2010/en#/V" memo="click here for list of ICD-10 diagnoses"] 
[textarea cols=80 rows=5 default="Diagnosis: unable to rate"]

IDENTIFICATION OF RISKS

[textarea cols=80 rows=5 default="Suicide: low risk"]

[textarea cols=80 rows=5 default="Self-harm: low risk"]

[textarea cols=80 rows=5 default="Violence: low risk"]

[textarea cols=80 rows=5 default="Vulnerability: low risk"]

[textarea cols=80 rows=5 default="Absconding: low risk"]

[textarea cols=80 rows=5 default="Risk to children aged under 18: low risk"]

[textarea cols=80 rows=5 default="Other risks: low risk"]

Suicide protective factors: [checkbox value="Treatment responsiveness|Connectedness to others|Problem solving skills|Coping skills|Ability to adapt to change|A sense of purpose or meaning in life|Beliefs that discourage self-injury|Social skills|Anger management|Good health|Access to health care|Fear of risky behaviours and pain|Hope for the future—optimism|Sobriety|Medical compliance|A sense of the importance of health and wellness|Impulse control|Sense of self-worth or self-esteem|Sense of personal control or determination|Access to a variety of clinical interventions|Support for seeking help
|Reasons for living|Married or a parent|Strong relationships with others|Opportunities to participate in and contribute to the world|A reasonably safe and stable environment|Restricted access to lethal means|Responsibilities and duties to others|Pets"].

[textarea cols=80 rows=5 default="Suicide: other notes"]

Factors affecting risk assessment: [checkbox value="Yes, patient name's presentation is highly changeable|No, patient name's presentation is not highly changeable|Yes, patient name's circumstances and supports are stable|No, patient name's circumstances and supports are not stable|Yes, patient name's assessment includes a corroborative history from friends, family and carers|No, patient name's assessment does not include a corroborative history from friends, family and carers|Yes, there are aspects of this assessment that require further clarification|No, there aren't aspects of this assessment that require further clarification."] 

IMMEDIATE ACTION PLAN

[textarea cols=80 rows=15 default="Problem / Issue: action planned."]

[textarea cols=80 rows=10 default="Discussed the issues and action plan with patient name and they are in agreement. Date."]

[textarea cols=80 rows=10 default="Discussed the issues and action plan with patient name's carer/parent/guardian and they are in agreement. Date. Additional comments. Contact number"]

[textarea cols=80 rows=10 default="GP is . Contact number. Address"]

[textarea cols=80 rows=10 default="Referrer is . Contact number. Address"]

[textarea cols=80 rows=10 default="Discussed the issues and action plan with team / senior clinician. Date. Additional comments."]

[textarea cols=80 rows=10 default="Additional contacts."]

Modules indicated for further assessment: [checkbox value="Physical|Metabolic|Appearance|Substance|COPMI (children of parents with mental illness|Functional assessment (older adults)|Transcultural|Consumer wellness plan|RUDAS (dementia)"].