MH Triage1

TRIAGE DETAILS

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

Time of assessment: [text default="time"]

Location: [text default="CMH"]

Referred by: [text default="sample text"]

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

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

Information taken: [checkbox value="via telephone|face-to-face|from EMR|from triage report|from colleague"] [text default=""]

Is the client aware of the referral?: [select value="yes|no|uncertain"]

Is a designated care provider aware of the referral? [select value="N/A|yes|no|uncertain"]

HISTORY

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

Medical issues: [textarea cols=50 rows=10 default="Nil known"]. 

-- Current treatments --

Medication: [textarea cols=50 rows=5 default="Nil known"]
Psychological: [textarea cols=50 rows=5 default="Nil known"] 
Complementary: [textarea cols=50 rows=5 default="Nil known"]
Other: [textarea cols=50 rows=5 default="Nil known"]

Legal Status and Forensic issues: [textarea cols=80 rows=10 default="Nil known"].

Current functioning and supports: [textarea cols=80 rows=10 default=""].

[comment memo=" Example of formulation: Pt presents with strong suicidal thoughts but no firm plan to act on these thoughts. This was precipitated by the recent breakdown of his marriage of 20 years. Historical factors contributing to this include: long history of depression, recent loss of job, and not attending to relationship challenges for a number of years. Pt reports this current pattern of dysfunction: he wakes up and just lies in bed ruminating, he can't eat or distract himself from miserable thoughts, he drinks alcohol too early in the day and texts his ex wanting her to return. Protective factors for Pt include: his dog, his kids who he loves, and supportive parents who are worried"].

Formulation: [textarea cols=80 rows=20 default="Pt presents with XXXX. This was precipitated by XXXX. Historical factors contributing to this include: XXXX. Pt reports this current pattern of dysfunction: XXXX. Protective factors for Pt include:"].

-- Mental Status Examination --

Pt is a [checkbox value="young adult|mid-aged adult|older adult|young teen|older teen|child"] [checkbox value="male|female"]. Grooming was [checkbox value="unable to be assessed|reasonable|neglected|meticulous"]. [checkbox value="+|++|+++"], [checkbox value="average weight|overweight|underweight"][checkbox value="+|++|+++"].
Posture was [checkbox value="unable to be assessed|relaxed|rigid|stooped|confident|aggressive|tense|slumped"][checkbox value="+|++|+++"]
Movement was [checkbox value="unable to be assessed|unremarkable|odd / peculiar|slowed|repetitive|restless|agitated|tremorous"][checkbox value="+|++|+++"]
Attention: [checkbox value="no concerns - attended well|seemed unaware|inattentive|distractible|hyper-vigilant|scattered concentration|preoccupied|confused|focused on irrelevancies"][checkbox value="+|++|+++"]
Engagement: [checkbox value="no concerns - engaged well|chatty|willing to open up|avoided eye contact|fixed staring|glaring at author|tense facial expression|dependent and needy|dramatic and exaggerating concerns|passive and difficult to engage|uninterested|silly and joking around|resistant|critical and verbally combative|hostile and threatening|sarcastic and taunting|irritable|fatuous|flirtatious|demanding|threatening|guarded|paranoid|defensive and resistant|manipulative|argumentative"][checkbox value="+|++|+++"]
Mood reported: [checkbox value="euthymic|sad|happy|ok|fine|angry|flat|depressed|neutral|worried|euphoric|dysphoric|apathetic|ashamed|irritable|hostile|pessimistic|manic"][checkbox value="+|++|+++"]
Affect observed: [checkbox value="congruent with reported mood|well regulated|incongruent with mood|constricted|labile|reactive|blunted."][checkbox value="+|++|+++"]
Speech: [checkbox value="spontaneous|normal RTV|abnormal RTV|clear and articulate|selectively mute|mute|loud|laconic|verbose|quiet|pressured|slowed|rambling|babbling|incongruent with mood and current circumstances"][checkbox value="+|++|+++"]
Thinking: [checkbox value="logical|linear|rigid and concrete|personalizing|persecutory|indecisive|unrealistic|difficulties of reference|magical ideas of influence|distorted|pseudologica fantastica|memory difficulties|provided unnecessary detail (circumstantial)|wandered between many topics (tangential)|jumped from one idea to another (loose associations)|racing thoughts (flight of ideas)|abruptly changed topic or stopped mid-sentence (thought blocking)|tended to loop or repeat themes (obsessive)|stuck on over-valued ideas (preoccupations)"][checkbox value="+|++|+++"]
Orientation: [checkbox value="no concerns|AH reported|VH reported|poor judgement|poor reality testing|poor insight|complete denial"][checkbox value="+|++|+++"]
Stressors disclosed without prompting: [checkbox value="nil|self-esteem|parenting|spouse|money|school|physical health|energy|sleep|body weight\shape|eating|food|housing|employment|mood|family|work|grief and loss|illness|transitions|legal|peers|relationship"][checkbox value="+|++|+++"]

Suicide risk: [checkbox value="denied active suicidal ideation when asked|vague suicidal ideation - i.e. 'what's the point of life'|occasional intense suicidal thoughts but can distract from them|intense and persistent suicidal ideation|has a vague plan - i.e. 'might overdose'|Pt disclosed they have the means to suicide|has a suicide plan but without strong intent|has strong intent to suicide without a plan|has strong intent and a plan to complete suicide|feels unable to keep themselves safe - feels out of control"]

Self harm issues (current or past): [textarea cols=80 rows=10 default="No documented history and no foreseeable concerns disclosed when asked."]

Violence Issues (current or past): [textarea cols=80 rows=10 default="No documented history and no foreseeable concerns disclosed when asked."]

Other issues affecting urgency: [textarea cols=80 rows=10 default="No documented history and no foreseeable concerns disclosed when asked."]

Factors affecting assessment: 

Is the patient's presentation highly changeable? [textarea cols=20 rows=1 default="Yes / No evidence of changeability"]
Are the patient's circumstances and supports unstable? [textarea cols=20 rows=1 default="Yes / No"]
Is corroborative information available from family, carers or others? [textarea cols=20 rows=1 default="Yes / No"]

CRISIS TRIAGE RATING SCALE - CTRS

[comment memo="The CTRS is intended to assist crisis staff to determine the level of risk and the urgency of response indicated in the assessment of a client call. The risk screening is done by asking a series of questions to determine whether a person is showing signs of emergency mental health, substance abuse or age related problems that requires emergency or immediate response or whether the individual can be safely support in the community.

This screening is used to support decisions about the most appropriate crisis intervention. The scale evaluates the person in crisis on a scale of 1 – 5 according to 3 factors: dangerousness, support System and ability to cooperate.

Questions A1 to A5 (ONLY answer 'yes' to one of these)"]

[select name="A1" value="No=0|yes=1"] <-- A1. Expresses or hallucinates suicidal/homicidal ideas or has made a serious attempt in present episode of illness. Unpredictable, impulsive and violent.

[select name="A2" value="No=0|yes=2"] <--A2. Expresses or hallucinates suicidal/homicidal ideas, without conviction. History of violent or impulsive behaviour but no current signs of this.

[select name="A3" value="No=0|yes=3"] <--A3. Expresses suicidal/homicidal ideas with ambivalence, or made only ineffectual gestures. Questionable impulse control.

[select name="A4" value="No=0|yes=4"] <--A4. Some suicidal/homicidal ideation or behaviour, or history of same but clearly wishes to control behaviour.

[select name="A5" value="No=0|yes=5"] <--A5. No suicidal/homicidal ideation/behaviour. No history of violence or impulsive behavior.

[comment memo="Questions B1 to B5 (ONLY answer 'yes' to one of these)"]

[select name="B1" value="No=0|yes=1"] <--B1. No family, friends or others. Agencies cannot provide immediate support needed.

[select name="B2" value="No=0|yes=2"] <--B2. Some support can be mobilized but its effectiveness will be limited.

[select name="B3" value="No=0|yes=3"] <--B3. Support systems potentially available but significant difficulties exist in mobilizing it.

[select name="B4" value="No=0|yes=4"] <--B4. Interested family/friends, or others but some question exists of ability or willingness to provide support needed.

[select name="B5" value="No=0|yes=5"] <--B5. Interested family, friends, or others able and willing to provide support needed.

[comment memo="Questions C1 to C5 (ONLY answer 'yes' to one of these)"]

[select name="C1" value="No=0|yes=1"] <--C1. Unable to cooperate or actively refuses.

[select name="C2" value="No=0|yes=2"] <--C2. Shows little interest in or comprehension of efforts made on his behalf.

[select name="C3" value="No=0|yes=3"] <--C3. Passively accepts intervention strategies.

[select name="C4" value="No=0|yes=4"] <--C4. Wants help but is ambivalent or motivation is not strong.

[select name="C5" value="No=0|yes=5"] <--C5. Actively seeks treatment, willing to cooperate.

Total Score --> [calc memo="CTRS Rating" value="score1=(A1)+(A2)+(A3)+(A4)+(A5)+(B1)+(B2)+(B3)+(B4)+(B5)+(C1)+(C2)+(C3)+(C4)+(C5)"]

[comment memo="Note: the interpretation of the CTRS may not reflect organizational time frames."]

Interpretation: [calc memo="interpretation" value="score=+(A1)+(A2)+(A3)+(A4)+(A5)+(B1)+(B2)+(B3)+(B4)+(B5)+(C1)+(C2)+(C3)+(C4)+(C5);score>16?'See patient within two weeks':score>14?'See patient within 24-48 hours':score>12?'See patient within 12 hours':score>11?'See patient within 2 hours':'An immediate response to the patient is recommended'"]

[comment memo="EXPLANATION OF SCORES

1 – 9: Extreme Urgency – immediate response requiring police involvement/ambulance (i.e. overdose, imminent violence, acute decompensation).

10: High Urgency – present to emergency department; contract for safety short-term follow-up (i.e. acute suicidality, threatening violence, acute severe non-recurrent stress).

11 – 13: Medium to Low Urgency  – promote support through 24/7 Crisis Line (i.e. distressed, suicidal ideation of moderate to severe nature, disturbed behavior, psychosocial crisis).

14 – 15: Non-urgent (See within 48 hours)– Problem solve with individual around resources for support that may be helpful to one’s present situation (referral to community organizations, Distress Centre line, addiction or MH services etc.)."]

ACTION PLAN

[textarea cols=80 rows=10 default="Action plan for Pt is "]
Other services involved:
[checkbox value="FACS|Child Wellbeing Unit Notified|Police Notified|Ambulance notified|Referred to inpatient Mental Health Service|Referred to Community Mental Health service|Referred to specialist Mental Health Service|Referred to Emergency Department|Referred to Community Health|Interpreter booked|Aboriginal Liaison Officer notified|Consult with Bilingual Mental Health Clinician(s)"]; [textarea cols=40 rows=5 default="Nil"]

Urgency of response: [checkbox value="Category A (3-9) Extreme Urgency, Immediate|Category B (10) High Urgency, Within 2 hours| Category C (11) Medium Urgency, Within 12 hours|Category D (12-13) Low Urgency, Within 48 hours|Category E (14-15) Non Urgent, Within 2 weeks|Category F Requires further triage contact/follow up|Category G No further action required"].

Contacts:

Communication undertaken with: [textarea cols=80 rows=10 default="Carer name; discussed the issues and action plan with (carer name) and they are (not) in agreement. Contact number. Comments. Date."]

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

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

Senior clinician: [textarea cols=80 rows=10 default=" (unable to) discussed the issues and action plan with team / senior clinician. Date. Additional comments."]

Additional contacts: [textarea cols=80 rows=10 default="Additional contacts name. Contact number. Details"].