MH Current Assessment 7

ASSESSMENT DETAILS

Date of assessment: [text default="date"] 

Time of assessment: [text 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=20 rows=1 default="This patient"] was referred to Community Mental Health for: assessment, treatment, monitoring, care planning, advocacy and linking with rehabilitation and support services.

HISTORY OF PRESENTING PROBLEM

On [text default="date"] this patient reported [textarea cols=50 rows=1 default="this event"] which exacerbated symptoms associated with [textarea cols=40 rows=1 default="diagnosis"].

Has assessment considered suicidal ideation, preparation or plans: Yes

Has assessment considered risk of harm to others: Yes 

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: Yes

Is the patient a smoker: [select value="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: [select value="No|Yes"]

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 healthy coping strategies, the patient identified:
[checkbox value="meditation|relaxation|self-care|physical activity|connecting with friends|a sense of humour|hobbies|spirituality|family support|work|meaningful activities|pets|walking|gardening|sleep hygiene|nutrition"] [textarea cols=40 rows=5 default="Nothing of note"]

When asked about maladaptive 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: [select value="No|Yes"]

Is the patient in an active carer or parental role to dependents: [select value="No|Yes"]

MENTAL STATE EXAMINATION

General: [select value="alert and oriented in all spheres|obtunded|disoriented"].
Appearance - build: [select value="average|solid|slim|underweight|severely|underweight|overweight|obese"].
Appearance: [select value="well kempt|poorly kempt|appropriately dressed|inappropriately dressed|appropriately groomed|inappropriately groomed|unable to rate"].
Appearance - accessibility: [select value="cooperative|friendly|uncooperative|hostile|alert|confused|hostile|silent|inappropriate boundaries|seductive|playful|ingratiating|evasive|guarded|sullen|manipulative|contemptuous|demanding|withdrawn"].
Appearance - grooming: [select value="Average/WNL|well-groomed|poorly groomed|meticulously groomed|minimal effort|unknown"].
Appearance - clothing: [select value="clean and casual|dirty and ragged|unkempt|neat and casual|tidy|meticulous|formal business attire|worn out|skillfully applied|unconventional|fashionable|unknown|professional|unable to rate"].
Appearance - hygiene: [select value="clean|unbathed|dirty|body odor|smells of alcohol|unknown"].
Psycho-motor activity - posture: [select value="quietly seated|relaxed|stooped|combative|hyperactive|agitated|rigid|stiff|shaky|slouched|bizarre movements|posturing|crouching|erect|restless|unable to rate"].
Behaviour - general: [select value="no apparent distress|mild distress|moderate distress|acute distress"].
Behavior - stability: [select value="calm|agitated"].
Behavior - interactivity: [select value="warm with comments and behavior|interactive but interpersonally cool|withdrawn"].
Behavior - eye contact: [select value="good|fair|avoidant|fleeting|unable to rate"].
Speech - clarity: [select value="clear|slurred|mumbled|lisping|stuttering|inaudible|incoherent|long pauses"].
Mood - stated: [select value="euthymic|upbeat|expansive|euphoric|anxious|flat|depressed|not stated|pt unable to describe"].
Affect - observed: [select value="euthymic|full range of affect|broad|appropriate|constricted|blunted|flat|labile|anhedonic|blunted|emotional withdrawal|excited"]. 
Mood/Affect - intensity: [select value="normal|mild|expansive|blunted|flat"].
Mood/Affect - congruence: [select value="mood congruent with affect|mood and affect are not congruent"].
Thought - form and flow: [select value="logical, relevant, and goal orientated|past orientated|scattered|impoverished|racing thoughts|circumstantial|perservations|flight of ideas|illogical|hopeful|remorseful|enthusiastic|incoherent|neologism|distractable|tangential|overvalued ideas|excited|poverty of though|word salad|clang associations|slow reaction|rapid reaction|doubting|indecisive|blocking|spontaneous|pressured|"].
Attention: [select value="no difficulty with attention or concentration|had some attentional and concentration problems"].
Perception - insight: [select value="normal insight|fair insight|poor insight"]
Thought - perception: [select value="within normal limits|illusions|hallucinations|denationalization|derealization"]
Thought - content: [select value="within normal limits|thought withdrawal|thought insertion|thought broadcast|suspiciousness|grandiose delusions|somatic delusions|delusional guilt|nihilistic delusions|ideas of reference|ideas of inference|magical thinking"].
Cognition/Memory: [select value="normal|grossly intact|below average|above average"].
Cognition/Memory - abstraction: [select value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"]
Judgment: [select value="normal|poor|fair|good"].
Suicidality: [select value="denied current ideation, plan, or intent|disclosed current ideation, but no current plan or intent|disclosed current ideation and plan, but no current intent|disclosed current ideation, plan, and intent"].
Other risks: [textarea cols=50 rows=5 default="No other risks identified"]. 

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 concerns to Community Services|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

FORMULATION

[text default="PATIENT"] presented to me on [text default="DATE"] complaining of [textarea cols=60 rows=10 default="SYMPTOM LIST"]. According to [text default="PATIENT"] these concerns became worse about [text default="DATE"], and were likely precipitated by [textarea cols=60 rows=10 default="PRECIPITATING EVENT"]. As a result, [text default="heshe"] is now struggling to cope with [textarea cols=60 rows=10 default="PROBLEM LIST"]. Historical factors which may have contributed to this current concern include [textarea cols=60 rows=10 default="FACTORS"]. [text default="PATIENT"] was able to identify some positive factors supporting recovery, such as [textarea cols=60 rows=10 default="FACTORS"].

DIAGNOSIS

[textarea cols=80 rows=5 default="Diagnosis: unable to rate"]

IDENTIFICATION OF RISKS

Suicide: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|previous attempt|current ideation, but no current plan or intent|current ideation and has a plan, but no current intent|current ideation, has a plan, and expressed intent"].

Self-harm: [select value="no current ideation or intent|historical self-harm reported|current ideation, but no intent|yes currently self-harms"].

Violence: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|historical violence reported|current ideation, but no current plan or intent|current ideation and has a plan, but no current intent|current ideation, has a plan, and expressed intent"].

Vulnerability: [textarea cols=80 rows=5 default="no foreseeable risks"]

Absconding: [textarea cols=80 rows=5 default="no foreseeable risks"]

Risk to children aged under 18: [textarea cols=80 rows=5 default="no foreseeable risks"]

Other risks: [textarea cols=80 rows=5 default="no foreseeable risks"]

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"].

Factors affecting risk assessment: [checkbox value="Yes, patient’s presentation is highly changeable|No, patient’s presentation is not highly changeable|Yes, patient’s circumstances and supports are stable|No, patient’s circumstances and supports are not stable|Yes, patient’s assessment includes a corroborative history from friends, family and carers|No, patient’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 and they are in agreement. Date."]

[textarea cols=80 rows=10 default="Discussed the issues and action plan with patient’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)"].