BINDING MARGIN DO NOT WRITE AHS: FACILITY: SERVICE UNIT: PLEASE PRINT CLEARLY PH 608 SURNAME MRN GIVEN NAME DOB SEX ADDRESS WARD/SERVICE UNIT Assessment completed date: / / Time: : Place: Preferred language: Interpreter: Not needed Needed Requested Booked Used Refused Refused by whom (Interpreter to countersign if possible) Telephone interpreter service number: 131450 Aboriginal Liaison Officer: Required Not required Reason for Presentation: Include time course, symptoms, impact, stressors, treatments and response to treatment ensure that consumer and carer (where consented) perspectives are considered. Consider culturally related views to wellness and illness and any recent resettlement. Mental Health history: Include recent admissions, treatments, self harm episodes, suicide and assault etc. ALERTS CURRENT RISK SUICIDE SELF HARM HARM TO OTHERS DV / ELDER ABUSE SUBSTANCE USE ABSCONDING / WANDERING FIRE RISK FALLS RISK DRUG REACTION / MEDICAL / ALLERGY ACCOMMODATION CHILD PROTECTION DOMESTIC SAFETY ISSUES VULNERABILITY SEXUAL ABUSE PHYSICAL ABUSE EXPLOITATION REPUTATION STAFF ALERTS ANIMALS ON PREMISES POOR LIGHTING LOCATION ISSUES UNWANTED VISIT WEAPONS OTHER: PLEASE NOTE THE CONSUMER S AND CARER S RIGHTS AND RESPONSIBILITIES SIGN OFF ON BACK PAGE SHOULD BE COMPLETED. MENTAL HEALTH A1 ASSESSMENT OF CURRENT PRESENTATION ADULT Page 1 of 12 (3/04)
Name: DOB: MRN: Medical History: Include all relevant conditions such as diabetes, head trauma, chronic pain conditions, HIV, Hep C, gynaecological & obstetric etc. Consider culturally related ideas and attitudes to changes in health. Medication: Include complementary / alternative medicines reported. Drug and dose Prescribed Comments Adherence: Include willingness and understanding of rationale to accept medications, insight and consider past experience. BINDING MARGIN DO NOT WRITE Adverse drug effects: Allergies: Please specify if drug related or food / environmental allergies. Current forensic issues: Page 2 of 12
BINDING MARGIN DO NOT WRITE PLEASE PRINT CLEARLY PH 608 SURNAME MRN GIVEN NAME DOB SEX ADDRESS WARD/SERVICE UNIT Current social situation: Please include consumer concerns and issues about domestic needs such as rent/mortgage, finances, gambling, dependents, pets, accommodation issues and social stressors such as cultural and ethnicity issues including settlement history, spirituality and religious beliefs, isolation and cultural conflicts. Does the consumer have any contact with children, for example, in their care, through access visits or sharing a residence? No Yes If yes, then you must complete the appropriate child protection form and file it with this assessment. If children not at risk, is there a plan of care in place to ensure their needs are met? Consider this when developing initial plan. Child s name Age Relationship to consumer MENTAL HEALTH A1 ASSESSMENT OF CURRENT PRESENTATION Violence and Abuse Issues: Consider past trauma / torture, sexual assault etc. ADULT Page 3 of 12 (3/04)
Name: DOB: MRN: Mental State Examination Appearance and Behaviour: Speech: Include quantity, rate, volume, tone and any unusual characteristics. Mood: Internal feeling or emotion eg depressed, euphoric or distressed. Affect: External emotional response eg restricted, flattened, inappropriate to circumstance. Thought (form & content): Include tangentiality, loosening of associations, illogical thinking, incoherence, blocking, poverty, preoccupations, obsessions, delusions, suicidal and homicidal ideation. Perception: Include illusions, depersonalization, derealisation, and hallucinations. Cognition: Include attention, concentration, orientation to time/place/person and memory. Insight and Judgement: BINDING MARGIN DO NOT WRITE Sleep and Appetite: Anhedonia: Page 4 of 12
BINDING MARGIN DO NOT WRITE PLEASE PRINT CLEARLY PH 608 SURNAME MRN GIVEN NAME DOB SEX ADDRESS WARD/SERVICE UNIT SCREENING FOR DOMESTIC VIOLENCE The domestic violence routine screening tool is to be used with women aged 16 and over and in accordance with screening protocols and the NSW Health Policy and Procedures for Identifying and Responding to Domestic Violence. You must explain this to the women being interviewed: In this Health Service we ask all women the same questions about violence at home. This is because violence in the home is very common and can be serious and we want to improve our response to women experiencing domestic violence. You don t have to answer the questions if you don t want to. What you say will remain confidential to the Health Service except where you give us information that indicates there are serious safety concerns for you or your children. Screening Questions: 1. Within the last year have you been hit, slapped or hurt in other ways by your partner or ex- partner? 2. Are you frightened of your partner or ex- partner? If the woman answers NO to both questions, give the information card to her and say: Here is some information that we are giving to all women about domestic violence. If the woman answers YES to either or both of the above questions continue to question 3 and 4. 3. Are you safe to go home when you leave here? 4. Would you like some assistance with this? Consider safety concerns raised in answers to questions. Action taken Domestic violence identified, information given Domestic violence identified, information declined Domestic violence not identified, information given Domestic violence not identified, information declined Support given and options discussed Reported to DoCS Police notified Referral made to Other action taken Other violence/abuse disclosed Yes Yes Yes Yes No No No No Screening was not completed due to: Presence of partner Presence of other family members Woman declined to answer the questions Other reason/ s, please specify MENTAL HEALTH A1 ASSESSMENT OF CURRENT PRESENTATION ADULT Page 5 of 12 (3/04)
Name: DOB: MRN: Alcohol and Other Drug Assessment Staff should ask all questions below. ALCOHOL 1. How much alcohol do you drink? Weekdays (Mon Thurs) Number of days How many per day? Weekday total = Weekend (Fri- Sun) Number of days How many per day? Weekend total = 2. How long have you been drinking alcohol at this level? 3. Date and Time of last drink? Amount? Note: High levels of consumption immediately prior to admission may indicate Intoxication & require management 4. Risk of Alcohol Withdrawal? (please tick) Yes No Note: Frequent or regular use may predict withdrawal syndrome TOBACCO OTHER 5. Do you smoke? Yes No If yes, how much? Note: Health professionals should discuss the health related risks of smoking and options for quitting 6. Do you use other drugs? (Document details on table below if substance use) Drug Type Usual dose Frequency Duration of use Benzodiazepines MDMA (Ecstacy) Amphetamines Cannabis Methadone Heroin Cocaine Route of administration Date & Time of last dose BINDING MARGIN DO NOT WRITE Analgesics Prescription Other (eg. Solvents) 7. Are you concerned about your substance use? Yes No 8. Risk of Withdrawal? (Please Tick) Yes No Note: Frequent or regular use may predict withdrawal syndrome Intervention Required: Please Tick Intervention Delivered: Please Tick Nil Nil Brief Intervention Brief Intervention Withdrawal management Withdrawal Management Intoxication management Intoxication Management Contact MO MO contacted - Time: Date: Refer to D&A Service D&A contacted - Time: Date: * If intoxication or withdrawal is suspected: Refer to NSW Health Clinical Guidelines and/or contact MO as indicated. Page 6 of 12
BINDING MARGIN DO NOT WRITE PLEASE PRINT CLEARLY PH 608 SURNAME MRN GIVEN NAME DOB SEX ADDRESS WARD/SERVICE UNIT Current level of functioning: Daily living skills, vocational, educational, interpersonal and recreational reference to relevant premorbid level of functioning. Ensure corroboration of this information whenever possible with consent. Consider cultural issues such as non recognised skills / qualifications and lost opportunities and socioeconomic standing. Assessment of strengths: Include effective coping strategies used, family cohesion, support networks, community participation, consider cultural influences such as spirituality / religion and capacity to establish a therapeutic alliance and factors that contribute to resilience and recovery. MENTAL HEALTH A1 ASSESSMENT OF CURRENT PRESENTATION ADULT Page 7 of 12 (3/04)
Name: DOB: MRN: Suicide risk assessment guide: At risk Mental State - depressed - psychotic - hopelessness, despair - guilt, shame, anger, agitation - impulsivity Issue High risk Medium risk Low risk Suicide attempt or suicidal thoughts - intentionality - lethality - access to means - previous suicide attempt/s Substance disorder - current misuse of alcohol and other drugs Corroborative History - family, carers - medical records - other service providers / sources Strengths and Supports (coping & connectedness) - expressed communication - availability of supports - willingness / capacity of support person/s - safety of person & others Reflective practice - level & quality of engagement - changeability of risk level - assessment confidence in risk level Eg. Severe depression; Command hallucinations or delusions about dying; Preoccupied with hopelessness, despair, feelings of worthlessness; Severe anger, hostility. Eg. Continual / specific thoughts; Evidence of clear intention; An attempt with high lethality (ever). Current substance intoxication, abuse or dependence. Eg. Unable to access information, unable to verify information, or there is conflicting account of events to that of those of the person at risk. Eg. Patient is refusing help; Lack of supportive relationships / hostile relationships; Not available or unwilling / unable to help. Low assessment confidence or high changeability or no rapport, poor engagement. Eg. Moderate depression; Some sadness; Some symptoms of psychosis; Some feelings of hopelessness; Moderate anger, hostility. Eg. Frequent thoughts; Multiple attempts of low lethality; Repeated threats. Risk of substance intoxication, abuse or dependence. Eg. Access to some information; Some doubts to plausibility of person s account of events. Eg. Patient is ambivalent; Moderate connectedness, few relationships; Available but unwilling /unable to help consistently. Eg. Nil or mild depression, sadness; No psychotic symptoms; Feels hopeful about the future; None/mild anger, hostility. Eg. Nil or vague thoughts; No recent attempt or 1 recent attempt of low lethality and low intentionality. Nil or infrequent use of substances. Eg. Able to access information / verify information and account events of person at risk (logic, plausibility). Eg. Patient is accepting help; Therapeutic alliance forming; Highly connected / good relationships and supports; Willing and able to help consistently. - High assessment confidence / low changeability; - Good rapport, engagement. No (foreseeable) risk: Following comprehensive suicide risk assessment, there is no evidence of current risk to the person. No thoughts of suicide or history of attempts, has good social support network. Is this person s risk level changeable? Highly Changeable Yes No Are there factors that indicate a level of uncertainty in this risk assessment? Eg: poor engagement, gaps in/ or conflicting information. Low Assessment Confidence Yes No If yes, please specify. BINDING MARGIN DO NOT WRITE Document your risk assessment details and plan here: Include self harm and risk to others, vulnerability to sexual / physical / financial harm, consider religious and spiritual beliefs that may influence risk. Overall suicide risk rating: High risk Medium risk Low risk No (foreseeable) risk Risk of harm to others: High risk Medium risk Low risk No (foreseeable) risk If any risk noted above, please tick ALERTS box on front page. Page 8 of 12
BINDING MARGIN DO NOT WRITE PLEASE PRINT CLEARLY PH 608 SURNAME MRN GIVEN NAME DOB SEX ADDRESS WARD/SERVICE UNIT Clinical impression/ formulation: Include issues to be addressed. Provisional diagnosis: Refer to ICD-10 manual or Your Guide to MH-OAT for diagnostic codes and guidelines. MENTAL HEALTH A1 ASSESSMENT OF CURRENT PRESENTATION ADULT Page 9 of 12 (3/04)
Name: DOB: MRN: Initial plan: Include plan for admission to inpatient unit or ambulatory care, any relevant treatment orders and document reasons for decision and plan undertaken. Are there any children / dependents / significant others in the care of this person whose needs/safety may need consideration due to this presentation? Detail here. If consumer not admitted to service, what follow-up arrangements, if any, were made? Have standard outcome measures been completed? Yes No Remember to commence relevant consumer care plan as soon as possible in the care setting. EARLY PSYCHOSIS INTERVENTION Does this person meet the criteria for treatment by an Early Psychosis Team? No Yes If yes, please refer to your local guidelines / protocols. BINDING MARGIN DO NOT WRITE Notifications: please circle Has the referral source been notified? Yes No Consent obtained Yes No Has the GP been notified? Yes No Consent obtained Yes No Has NOK/significant other been notified? Yes No Consent obtained Yes No Other services / persons notified? Yes No Consent obtained Yes No Please document which other services / persons notified eg DoCs. PLEASE ENSURE THAT THE CONSUMER AND THEIR CARERS / SIGNIFICANT OTHERS HAVE BEEN INFORMED OF THEIR RIGHTS AND RESPONSIBILITIES. AN INFORMATION PACK SHOULD BE MADE AVAILABLE TO ALL PARTIES INVOLVED IN THE ONGOING CARE AND SUPPORT OF AN INDIVIDUAL. I understand my rights and responsibilities and/or have received an information pack. Consumer signature: Carer signature: Page 10 of 12
BINDING MARGIN DO NOT WRITE PLEASE PRINT CLEARLY PH 608 SURNAME MRN GIVEN NAME DOB SEX ADDRESS WARD/SERVICE UNIT ADDITIONAL NOTES MENTAL HEALTH A1 ASSESSMENT OF CURRENT PRESENTATION ADULT Page 11 of 12 (3/04)
Name: DOB: MRN: ADDITIONAL NOTES BINDING MARGIN DO NOT WRITE Page 12 of 12