Mental Health Review

Transcription

1 Document reference: MHRAPR14V9 RT2 Number: Mental Health Review Full Name: Date of Birth: NHS Number: Section 117 applies YES NO Discharged from S.117 YES NO Date of discharge from Section 117 SCT YES NO Review Types: Review (CPA) or Treatment Care Plan Review (Non CPA) (please tick one option below) Planned CPA Follow Up Review Planned Non CPA Review (Treatment / Care plan) Unplanned CPA Follow up Review Unplanned Non CPA Review (Treatment / Care plan) Date Review Started: Time Review Started: Date Review Completed: Time Review Completed: Completed By (Reviewer Name): Team: Role: Location of Review: Please see Code Lists Location of Assessment for options) PEOPLE PRESENT AT/ INVOLVED IN THE REVIEW Name: Role : Present / Involved Copy of Care plan required Yes No CONSENT: May we share information about your care and treatment with your carer/family? YES NO SOME N/A If SOME, what information do you not wish us to share with them? HOW WE USE YOUR INFORMATION: The information that you give to us will be used to assess and provide suitable Health and Social Care services. It will be held securely and in confidence. We may need to share your information with other Health and Social Care providers to provide you with the appropriate services. Our service user information leaflet entitled How we will use your information will explain this in more detail. Have you been given the How we use your information leaflet? YES NO If not, would you like a copy? SECTION 1 : REVIEW OF CURRENT CARE PLAN (In Service User s / Carers Views) Review of Current Care Plan: ( Inc Service Users / Carer views ) YES NO Page 1 of 17

2 SECTION 2: CURRENT SOCIAL / PERSONAL CIRCUMSTANCES UPDATE (Include Social Functioning) Accommodation: (include any changes to status/ tenure) Accommodation Status : (See separate code list) Employment Education and Training: ( include any changes to Status) Employment Status : Employed Other Inc Education/Training /Volunteering (please specify) Not Disclosed Unemployed Not applicable Retired Unknown If none of the above, has the service user been referred to any of the following: Educational organisation YES NO Voluntary YES NO Employment organisation YES NO Other YES NO Please give details of Organisation: Page 2 of 17

3 Areas for consideration at review: Leisure / Social Activities / Networking: Finances / Welfare Benefits: Family / Close Relationships: Child Care / Parenting Issues: Consider what is the impact of mental health problems and / or substance misuse on parenting capacity and caring for children. (If there are any concerns re: Safeguarding Children please provide details in Section 6 below): Advocacy Needs: Culture, Faith, Religious and Spiritual needs: Daily Living and Personal Care: Drug And Alcohol Use: Does the individual have a Drug dependency? Yes x No x Does the individual have an Alcohol dependency? Yes x No x Has the service user served in the armed forces? (Please select from tick list) 01 Yes Currently serving (including reservists) 02 Yes ex services 03 No 04 Dependant of current serving member 05 Dependant of ex-serving member UU Unknown (Person asked and does not know or isn t sure) ZZ Not Stated (Person asked but declined to provide a response) Page 3 of 17

4 SECTION 3: MENTAL HEALTH UPDATE Include Psychiatric and Psychological Functioning Is a full MSE required? Yes/ No (If Yes - Complete MSE Appendix 1) MENTAL CAPACITY Are there any issues/ concerns regarding the Service User s Mental Capacity to consent to either admission or medication? ( if yes please give brief details ) YES/ NO Does the person have an active advance decision or advance statement in place? Or have they chosen to refuse any form of treatment in the past? (If yes please provide brief details (inc where details are held)) YES / NO Does the person have a Lasting Power of Attorney or Court Appointed Deputy in place? (if yes please provide details) YES / NO Is a Deprivation of Liberty Safeguards Authorisation required? YES/ NO Page 4 of 17

5 SECTION 4: PHYSICAL HEALTH Service user/carer s view of current physical health: PHYSICAL HEALTH CHECKS FOR ALL SERVICE USERS Is the Service User registered with a GP practice? YES NO If NO, what actions are being taken to ensure that the Service User registers with a GP? If the Service User is not registered with a GP (or does not want to register with one), what actions are being taken to ensure that the Service User has an annual physical health check? If YES, has the Service User had an annual physical health check completed by the YES NO GP? If NO, or the Service User does not want to go to their GP for an annual physical health check what actions are being taken to ensure that the Service User has an annual physical health check? If YES, has the GP been asked to provide details of the physical health check? YES NO If YES, has it been received? YES NO If YES please provide details if the GP has highlighted any concerns about the Service User following their physical health check Page 5 of 17

6 If NO, please explain why: Are there any other concerns about the Service Users physical health? YES NO Please consider the following areas: Cardio-Vascular History, Diabetes, Liver or Kidney Function, Body Mass Index etc If necessary, refer to the Physical Health Care Policy (CL42) for further guidance. Please provide details below: Does the Service User smoke? (if yes, please complete full smoking assessment) YES NO Is further action required at this stage? YES NO (if yes, please state actions required and include in Care Plan) A FULL PHYSICAL SCREEN AND EXAMINATION SHOULD BE COMPLETED ON ADMISSION AND REVIEWED AS PART OF FURTHER ASSESSMENT IF ACCEPTED INTO SECONDARY CARE MEDICATION HISTORY AND RECONCILIATION Allergies/Adverse drug reactions: Current Medication at time of Review : Please list all medication including: currently being obtained from GP, obtained over the counter / non prescribed, bought or obtained from other sources e.g. herbal Drug Dose Form Indicatio n (If known) Shortterm (please tick) How long has the patient been taking this medication? Has there been a dose change in the last 4/52? Patient s own available (admissions only) Page 6 of 17

7 SECTION 5: RISK ASSESSMENT DOMAIN: HARM TO SELF / SUICIDE Past History: Include; incident/events, what, where, when (dates please), and who was involved, cause/trigger, consequences and risks. Consider family history of suicides Current Situation: include service user and carer/parent/guardian views, consider STORM paperwork as alternative Level of thoughts/plan/intent/behaviour/means to harm self. Responding to command hallucinations. Level of distress, helplessness / hopelessness. Demographic and situational risk issues e.g. age, employment, relationship status, major life events or anniversaries Support network and coping strategies Factors Increasing Risk: Substance use, including alcohol, illicit substances and prescribed medication, consider accidental risks Factors Decreasing Risk: Activities, support networks Page 7 of 17

8 DOMAIN: HARM TO OTHERS/ VIOLENCE Past History: Include; incident/events, what, where, when (dates please), and who was involved, cause/trigger, consequences and risks Past evidence of Carrying/using weapons or Dangerous impulsive act(s). Denial of previous dangerous acts / (offences). Lack of remorse for previous dangerous acts. Forensic history, Index offences, Admission (s) to secure settings Current Situation: include service user and carer/parent/guardian views Intent or plan (inc Access to named potential victims), expression of concern from others about risk of violence. Paranoid delusions about others (inc: children). Violent command hallucinations. Preoccupation with violent fantasy. Current evidence of Carrying/using weapons. Sexually inappropriate behaviour (beliefs or thoughts). Contact with children, vulnerable and older adults Factors Increasing Risk: Substance misuse/poor concordance/role of mental health/situational and context issues Factors Decreasing Risk: Engagement. Abstinence from alcohol/drugs Compliance with treatment/medication Page 8 of 17

9 DOMAIN: Exploitation / Vulnerability Past History: Include; details of past neglectful situations;- what, where, when (dates please), and who involved, consequences for client and abuser, Safeguarding and police issues. Abuse by others e.g. physical / sexual / psychological / financial / domestic etc (Signs/ allegations), Period (s) of neglect by others (inc by parent/carer), Exploitation, Harassment / bullying. Religious / spiritual persecution, Presence of negative social contacts Current Situation: include service user and carer/parent/guardian views Parent / carer non compliance with medical /physical interventions, Concerns about parental mental illness / substance misuse), Significant Disability inc. Cognitive, physical and or sensory,impact of mental health0n risk. Wandering, Absconding / missing ( inc not attending school), Falls, unexplained injuries, mobility problems, Inability to maintain safe environment ( inc lack of parent/ carer supervision) Factors Increasing Risk: Substance misuse, Non compliance with care / treatment arrangements ( inc parental non compliance), Poor relationships Factors Decreasing Risk: Reverse of above. Engagement with prevention strategies, role of safeguarding procedure Page 9 of 17

10 DOMAIN: SELF NEGLECT Past History: Include; details of past neglectful situations;- what, where, when (dates please), and who involved. Current Situation: include service user and carer/parent/guardian views Difficulties maintaining personal hygiene, failing to eat/ drink adequately, inappropriate clothing, Substance misuse, nutrition, physical health, dental health. Cognitive impairment, Difficulties communicating needs Factors Increasing Risk: Financial difficulties, inadequate accommodation, lack of basic amenities, lack of supportive social contacts, major life events. Non compliance with care / treatment arrangements (inc parental non compliance). Disengagement from services. Factors Decreasing Risk: Reverse of above, care approach Page 10 of 17

11 SERVICE USER S / FAMILY / OTHERS PERSPECTIVE Service User s Perspective Was the service user involved in the risk assessment? (Please provide details) YES/ NO Does the service user agree with the findings of this risk assessment (Please provide details) YES/ NO/ UNABLE TO AGREE Service User Perspective Family/ Carer/ Other Perspective RISK SUMMARY AND FORMULATION Summary Formulation consider the nature and degree of risk, who is at risk, how likely is it, relationship between risk and mental disorder, current social circumstances or contextual factors Is more information needed Are there any safeguarding issues relating to adults (Please refer to Section 7 Safeguarding Adults details) Are there any safeguarding issues relating to children After considering the impact on parenting capacity, do you have child safeguarding concerns either from direct dialogue or from your professional judgement? (Please refer to Section 6 Safeguarding Children for details) Next steps YES / NO YES / NO YES / NO Signed Dated: Page 11 of 17

12 SECTION 6: CHILDREN AND SAFEGUARDING ISSUES Are there any changes to the information regarding the children whom the person has significant contact with? (if yes please update records) If the service user has children under 18 where are they now (in school, college, with relatives / partner) Yes / No Are there any concerns that the mental health of the service user has impacted on or may impact on the child? Yes / No Is the service user likely to have or resume significant contact with their own children or other children (please provide details) Yes / No Does the person have delusional beliefs involving the children (please provide details) ( if Yes, refer to Consultant Psychiatrist for involvement in clinical decision making) Yes / No Is there concern that the service user might harm their child / unborn child as part of suicide plan please provide details ) ( If Yes, refer to social services immediately and refer to Consultant Psychiatrist for involvement in any clinical decision making ( refer to child protection policy for guidance) Yes / No Views of other people / family members Is any further Action needed at this stage Issues Relating To Safeguarding Adults SECTION 7: SAFEGUARDING ADULTS Actions required / taken Page 12 of 17

13 Update on Carer s Needs: CARERS CARERS ASSESSMENT CHECKLIST Is a separate carer s assessment required? Yes / No If Yes has one been offered? Yes / No If No please state reason: Has carer assessment leaflet been provided to the carer If No please state reason: Yes / No SECTION 8: OUTCOME Outcome of review (additional needs identified / actions required and by who) MAPPA eligible? Yes / No If yes, please complete Form G, available from the Mental Health Law Office, and submit to relevant MAPPA co-ordinator Review Outcome: Care Plan Amended Adjourned Discharged with info and Advice Care Plan Unchanged Cancelled Discharged from all services New Care Plan Discharged Discharged / referred on End date of previous care plan: Start date of new/ revised care plan: Discharge reasons Finished against professional advice Treatment complete Transfer to other NHS Institution Transfer to high Secure Finished on professional advice Transfer to other Health provider Transfer to Medium secure Unable to be treated Description of Presenting MH problem / Diagnosis/Symptom: (see code list- Appendix 2) (note to admin this information is to be entered in the coding tab via the referral tab) REVIEW AGREEMENT Page 13 of 17

14 Do you agree with the details in this review? Service User Yes/ No ( if No please state why) Family/ Carer Yes / No ( if No please state why) Would you like a copy of your review? YES/NO If Service User declines to sign state reason(s) why: Have you been given information on how to make a comment / compliment / complaint YES/NO If not, would you like a copy? YES/NO Has any other relevant information been offered YES/NO Service User s signature: Reviewers signature: Date Of Next Planned Review: Date Date CPA STATUS DECISION RECORD Is person currently on CPA: Yes / No Is CPA Required / Still Yes / No Required: Details Of Decision Regarding CPA Status: ( Please Give Details Of all those Involved( inc name and designation) In the discussion, the outcome, reasoning and subsequent actions) Date Of Decision : Allocated Care Coordinator Name : Date of Next Planned Review: Designation: Team: Contact Details: Signature: Page 14 of 17

15 RT NUMBER: PATIENT NAME: DOB: MENTAL HEALTH CLUSTERING TOOL New Referral CPA Review Review (Non CPA) Other Significant Change Other Not elsewhere specified Not Known SCORE No ITEM DESCRIPTION: No problem Minor problem requiring no action Mild problem but definitely present Moderately severe problem Severe to very severe Unknown Last 2 weeks Overactive, aggressive, disruptive or agitated behaviour 2 Non accidental self injury 3 Problem drinking or drug taking 4 Cognitive Problems 5 Physical Illness or disability 6 Hallucinations and delusions 7 Depressed Mood 8 Other Dissociative Anxiety Ob. Com Stress Sleep Type: Symptoms Somatoform Eating Phobic Sexual Other 9 Relationships 10 Activities of Daily Living 11 Living Conditions 12 Occupational & Activities (provision and access) 13 Strong un reasonable beliefs Historical A Agitated behaviour / expansive mood B Repeat Self harm C Safeguarding other children & Vulnerable dependant adults D Engagement E Vulnerability CLUSTERING No: Cluster Description with brief description 0 Variance Cluster: unable to identify any other appropriate cluster or no mental health issues identified 1 Common Mental Health Problem (Low Severity): sub-clinical depression/anxiety. No identified needs 2 Common Mental Health Problem (Low Severity With Greater Need): slightly higher need than cluster 1 3 Non Psychotic (Moderately Severe): mild common mental health concern. Low level of risk 4 Non Psychotic (Severe): moderate common mental health concern. Lower level of common need 5 Non Psychotic Disorders (Very Severe): Severe common mental health concern. Not complex. 6 Non Psychotic Disorders or Over Valued Ideas: Complex with focus on psychological input 7 Enduring Non Psychotic Disorders (High Disability): Complex and chronic. 8 Non Psychotic Chaotic and Challenging Behaviour: Relevant history of self harm that is high risk 10 First Episode Psychosis: Traditional EIT service user 11 Ongoing Or Recurrent Psychosis (Low Symptoms): Low / No symptoms or needs for the past year 12 Ongoing Or Recurrent Psychosis (High Disability): Chronic moderate level of holistic need 13 Ongoing Or Recurrent Psychosis (High Symptoms and Disability): high level of need 14 Psychotic Crisis: suitable for crisis/hit/ht or inpatient input 15 Severe Psychotic Depression: psychosis and depression suitable for crisis/hit/ht or inpatient input 16 Dual Diagnosis: Severe mental illness and substance misuse 17 Psychosis And Affective Disorder Difficult to Engage: Traditional AOT service user 18 Cognitive Impairment (Low Need): Low level of input and low holistic need 19 Cognitive Impairment or Dementia Complicated (Moderate Need): Moderate holistic need 20 Cognitive Impairment or Dementia Complicated (High Need): High holistic need 21 Cognitive Impairment or Dementia (High Physical or engagement): Long term physical health needs COMMENTS: DATE COMPLETED: COMPLETED BY : NAME : DESIGNATION: Page 15 of 17

16 Appendix 1 CURRENT MENTAL STATE EXAMINATION Include Individuals and Carers view of Current Mental Health Appearance / behaviour and Rapport: Speech: Mood: Subjective: Objective: Thoughts: Perception: Cognitive function: Judgement / Insight: Date Complete : Completed By: Page 16 of 17

17 Appendix 2 Description of Presenting MH Problem Diagnosis / Symptom Behavioural & emotional disorder onset childhood & adolescence Mental disorder, not specified Personality disorder Bipolar affective disorder Mild depressive episode Phobia anxiety disorder Dementia Mixed anxiety & depression Puerperal (post natal) mental disorder Delirium Moderate depressive episode Reaction to severe stress & adjustment disorder Dissociative (conversion) disorder Panic Disorder Schizophrenia Disorder due to alcohol use Non-organic psychosis Sexual dysfunction Disorder due to drug use Non-organic sleep disorder Severe depressive episode without psychotic symptoms Disorder of psychological development Obsessive compulsive disorder Severe depressive episode with psychotic symptoms Eating disorder Other anxiety disorder Somatoform disorder Page 17 of 17