Assignment title: Information

 Inpatient  DEM  CCT/MOT/CCU  CA TT  Consultation-Liaison PATIENT IDENTIFICATION LABEL UR Number: Surname: Given Names: Date of Birth: Sex: ..... GENERAL INFORMATION SHEET ASSESSMENT BY: (block letters) _____________________ Role: SITE ASSESSED: _ DATE: __________ TIME: _ CONTACTS (names & telephone numbers) Case Manager: ___________ Phone No.: CMHS Treating Doctor: _ Phone No.: _ GP: _______________________________________________ Phone No.: _ Private Psychiatrist: __________________________________ Phone No.: _ Guardian/Carer: _____________________________________ Phone No.: _ Relatives: __________________________________________ Phone No.: _ Other Agencies: _____________________________________ Phone No.: _ MENTAL HEALTH ACT STATUS (Circle): Informal ITO Inpatient ITO Community Date of Review SPECIALITY UNIT ADMISSIONS / ASSESSMENTS Mother and Baby Name of Baby: __________ DOB: _ Formula: ___________ Medical Problems: Protective Issues: Eating Disorder Weight:: Height: _ BMI: _____________________ Medical Problems: Premorbid Weight:: _ REFERRAL SOURCE Name: ____________________ Agency: _ Contact No.: _ Urgency: ____________________________ Risk Assessment by Referrer: Self Others (including infant)_ Property._____________________________________________________________ First Language of Patient: _ Facility with English: _ Interpreter required Y/N Presenting Problem (summary): Nominate MHA status, ie EEO JEO R&R Obtain a brief description of the principal complaint and the time frame of the problem in the individual’s own words. The individual's concerns need to be taken seriously. Respect and empathy will enhance trust. The individual's description of the problem will also enable the clinician to assess the individual's description of the problem and will also enable the clinician to assess the individual's insight or perception into his or her situation. Specifically, find out: • What is the nature of the problem? • Why and precisely how has the individual presented / at this time? • What events led up to this presentation? • Who else is involved? Social Circumstances and Culture: Social Circumstances: Social network or social supports, socio-economical background, stability of network, attitudes towards others within network or background, social popularity, participation in society, social isolation, social skills, relationships Culture: Ethnicity, sexuality, customs, political background Details of Present Illness: • Include prodrome, onset, symptoms, course, stressors, associated features, relevant negatives. • It will be important for the clinician to identify information that is relevant and useful and to bypass information that is not as useful. An important part of history taking involves probing for useful information that the individual does not mention spontaneously. • Some individuals (eg, those who are brought into the assessment by others) may deny the existence of a problem. In these circumstances it may be necessary to obtain a history of the illness from a family member or close friend. You will need to obtain the following information: • Identify specific symptoms that are present and their duration. • Note time relationships between the onset or exacerbation of symptoms and the presence of social stressors / physical illness. • Note also any disturbance in mood, appetite, sexual drive and sleep. • Obtain information about any treatments given by any doctors or specialists for this problem, and the individual's response to treatment. Drugs and Alcohol: • Find out about present or previous drug or alcohol use (prescribed medications, self-prescribed, or illegal), and responses to each of these drugs. Are there any adverse (including allergic) drug reactions? Forensic: • Illegal activities / violence. Criminal record and any previous episodes of violence such as pub brawls, violence at home, or acts of aggression. Any antisocial traits? Medications: • Including compliance, recent serum drug levels, special monitoring tests. • Include; type, dose, frequency, prescribing source, commencement date. • Depot dose and frequency. • Date next due for depot. Past Psychiatric History: • Including previous admission details, treatments, responses to treatment. • Obtain information about all physical, psychological or emotional disorders for which professional help has been obtained. • Details can include, patient symptoms, extent of incapacity, type of treatment, names of Hospitals / services, length of each illness, effects of prior treatment, complications with treatment and degree of compliance. • Particular attention should be given should / be paid to the first episode that signalled the onset of illness, and the presence of known early warning signs. • Information on previous precipitating events, diagnostic possibilities and coping capacity. ____________________________________________________________________________________________________________________________________________________________________________________________________________ Past Medical History, Allergies: • Major medical or surgical illness and major traumas, particularly those requiring hospitalisation. • Episodes of cranio-cerebral trauma, neurological illness, viral illnesses eg. Glandular fever, Ross River, tumours and seizure disorders. Also HIV / AIDS and history of infection with STD’s / syphilis. • The cause effect, complications and treatment of any illness should be noted. • Specific questions regarding possible psychosomatic disorders could be asked. Included in this can be, hay fever, rheumatoid arthritis, asthma, hyperthyroidism, gastrointestinal upsets, recurrent colds/flu's, skin conditions and recurrent viral infections. Family History and Genogram: Includes family history and cultural background. Ask about the individual's close family (ie, spouse, children, parents, and siblings). For each member of the immediate family, obtain information about: • Age • Health • Occupation • Personality description • Quality of relationship with that person • Psychiatric and other illnesses (including alcoholism and other substance abuse) • Treatment for any identified family illnesses • Response to treatment • Carers attitude to problems It may also be helpful to ask about the presence of psychiatric illness in grandparents, aunts, and uncles. A genogram may be of assistance. A general guide to constructing a genogram is; record names, ages and sex of siblings, parents, children. Record in order of birth. Give age and cause of death. Note familial disease, eg. alcoholism, epilepsy, intellectual disability, mental illness, and recurrent physical disorder specify.  MALE O FEMALE   IDENTIFIED CLIENT  O  Death Married Relationship  O  O Unmarried Relationship Divorce  O Conflictual   Twins Personal History: The personal history covers many aspects of the individual's life, from childhood through to adulthood. Obtain information about: • Birth, early development, trauma / abuse, school, work, psychosexual development, offspring. • Infancy (drug treatments during pregnancy; emotions and temperament; level of activity; nourishment; general development). This information is generally only important if the index individual is a child. You will need to obtain this information from the child's parents or guardians. • Childhood and adolescence (emotional adjustment; relationships with peers, siblings and parents; play; trait anxiety; physical illnesses; sleeping behaviour; mental and motor development; early loss of close family members; sexual or physical abuse; belonging to a group; relating to peers and adults; school history; extent of sexual activity). • Work history (jobs held; reasons for changing jobs; level of satisfaction with employment; ambitions). • Marital history (number of marriages; duration; quality of relationships; personality of spouse/s; reasons for break-up of relationship/s). • Relationships with others (intimate or sexual relationships; presence of someone in whom to confide). • Children (name; sex; age; mental and physical health). • Forensic history, illegal activities / violence (ask about criminal record and any previous episodes of violence such as pub brawls, violence at home, or other acts of aggression). Premorbid Personality: How does the individual describe his or her personality before becoming unwell? Note: • Overall mood or temperament • Character traits • Confidence • Religious and moral beliefs • Ambitions and aspirations • Social relationships with family, friends, workmates Mental State Examination Appearance: General health, obvious weight change, dress, self-care, apparent age, make-up, body type, posture, clothes, grooming, un/healthy? ill at ease? attitude to interview? hostile? friendly? withdrawn? seductive? tense? signs of anxiety? There has been weigh gain in the last year. Self-cares are not really attended to, does not shower on a regular basis. Jonathon is aged 35 although appearance wise looks like he is in his 40’s. Body posture is very hunch back does not sit up straight, doesn’t dress very well, first meeting he wore a white singlet with stains on it. His attitude towards the interview displayed he did not want to be there but only attended to make his wife happy. Behaviour: Gait, motor activity, posture, abnormal movements, facial expressions, eye contact, non-verbal communication, agitation? pacing? psychomotor retardation? restlessness? aimless / purposeless behaviour? Speech: accent, mannerisms, stereotypes, impediment, volume, loudness, tone, articulations, impediment, echolalia, garrulous (talkative)? voluble (at length)? taciturn (saying little)? normally responsive to cues? rapid or slow? pressured? hesitant? monotonous? whispered? slurred? mute? Mood: Underlying emotional tone over time ie. depressed? despairing? apathetic? irritable? angry? guilty? labile? elation? euphoria? hostile? Affect: (observed emotional state during interview) Quality: euthymic (sense of wellbeing), elevated, euphoric (extreme wellbeing), elated, depressed, anxious, fearful, angry, irritable, suspicious, guarded, or perplexed. Range: Normal, diminished, restricted, blunt, flat, increased, labile. Appropriateness: appropriate/inappropriate, incongruous/congruous (inappropriate). Communication: normal, well-communicated, poorly communicated, shallow, indifferent. Thought: Stream: normal, increased, decreased, pressured. Form: no formal thought disorder (NFTD), tangential (Iooses thread of conversation), flight of ideas (topic jumping), loosening of associations (one idea reminds of another), derailing, circumstantiality (loss of goal directed ability), neologisms (new words), clanging (rhyming), punning (double meanings), interpretation of themes, thought blocking (stopping of a thought half way), incoherence, perseveration (repetition of same idea or word in response to different questions). Content: themes, obsessions, delusions, phobias, compulsions, overvalued ideas, suicidal ideation, homicidal ideation, delusions (persecutory, grandiose, of reference, religious, erotomaniac (preoccupation with sexuality), of jealousy, nihilistic (belief everything no longer exists), of poverty, of guilt, of worthlessness), hypochondriacal (morbid anxiety about one’s health), dysmorphophobic (fear of a deformed body part), bizarre, delusional perception, delusional mood / memory. Possession: delusions of thought alienation, thought insertion, thought withdrawal (belief thoughts are being withdrawn from ones’ head), thought broadcast (belief thoughts are broadcasted to outside world), made actions, made impulses, or made feelings. Perception: illusions, mis-identifications, depersonalisation (feeling body is not real), derealisation (environment is strange or unreal), passivity experiences (dependence on others/childlike), Capgras Syndrome (belief people have been replaced with doubles). Hallucinations: auditory (discussing or arguing, command, or commenting), visual, somatic, tactile, olfactory (smell), gustatory (taste), hypnagogic (while falling asleep), hypnopompic (waking up). Cognition: (alternatively complete MMSE) (Note Visual or Hearing deficits) Attention: capacity to sustain level of concentration Concentration: serial 7's, spell WORLD backwards, months / weekdays backwards, Orientation: time, person and place (TPP), Memory: Immediate recall - immediate recall of 3 objects, Short-term - recall of above 3 objects minutes later, Long-term - information about childhood, past news. Intelligence: from history, schooling, vocabulary, resourcefulness Capacity for Abstract Thought: difference / similarities, proverbs) Insight: - belief that has illness - attitude to treatment Judgement: ability to understand the likely outcome of behaviour and how they are influenced by the understanding. Interviewer's response to patient: rapport, credibility, countertransference RISK ASSESSMENT I MANAGEMENT SUICIDE POTENTIAL Primary Risk Factors: () Present () Absent (0) Unknown 1. Current lethality / attempt  Suicide attempt with lethal method (firearms, hanging/strangulation, jumping from high places)  Suicide attempt resulting in moderate to severe damage to toxicity  Suicide attempt with Iow "rescue-ability" (no known communication regarding the attempt, discovery unlikely because of chosen location and timing, no one nearby or in contact, active precaution to prevent discovery)  Suicide attempt with subsequent expressed regret that it was not completed AND continued expressed desire to commit suicide OR unwillingness to accept treatment 2. Intent (includes suicidal thoughts, preoccupation, plans, threats & impulses, whether communicated by the client directly or by another person based on observation of the client)  Suicidal intent to commit suicide very soon  Suicidal intent with a lethal method selected and readily available  Suicidal intent AND preparations made for death (writing a will or a suicide note, giving away possessions, making certain business or insurance arrangements)  Suicide intent without ambivalence or ability to see alternatives to suicide  Presence of acute command hallucinations to kill self whether or not there is expressed suicidal intent  Suicidal intent with CURRENT ACTIVE psychosis, especially major affective disorder or schizophrenia  Suicidal intent or other objective indicators of elevated suicide risk but mental condition or lack of cooperation preclude adequate assessment If one factor present, consider risk serious, and consult with colleague Secondary Risk Factors: The following factors all significantly contribute to suicide risk but are of a less critical nature. For the purpose of this instrument, all factors are considered of equal importance. () Present () Absent (0) Unknown  Recent separation or divorce  Recent death of significant other  Recent loss of job or severe financial setback  Other significant loss/stress/life changes interpreted by client as aggravating (victimisation, threat of criminal prosecution, unwanted pregnancy, discovery of severe illness, etc)  Social isolation  Current or past major mental illness  Current or past chemical dependency/abuse  History of suicide attempt(s)  History of family suicide (include recent suicide by close friend)  Current or past difficulties with impulse control or antisocial behaviour  Significant depression (whether clinically diagnosable or not), especially accompanied by guilt, worthlessness or helplessness  Expressed hopelessness  Rigidity (difficulty with adapting to life changes) If seven “” or more, consider risk serious Demographic Risks: Not to be included in the ratings, but considered in overall assessment of suicide risk  Male (especially older, white male)  Living alone  Single, divorced, separated or widowed  Unemployed  Chronic financial difficulties  Chronic medical illness Consider demographic factors as additive to risk only Risk Assessment (Suicide Potential): Immediate Minimal Extreme Longer term Minimal Extreme  Consultation sought from another staff member  Team advised  Collateral information obtained  Supportive/Key others informed Mitigating factors/strengths: _ ______________________________________________________________________________________________________________________ Action Plan: Consider: hospitalisation, supportive networks, possible mitigating strategies, medication requirement, validity of any guarantees, etc). _ ________________________________________________________________________________________________________________________________________________________________________________________________________________________ Action Plan incorporated into and documented in Treatment Plan: _ VIOLENCE POTENTIAL Primary Risk Factors: () Present () Absent (0) Unknown 1. Assaultiveness  Current or previous assault involving a weapon  Current or previous assault involving an injury to another  Current or previous assault with regret victim escaped and continued expressed intent or unwillingness to accept intervention  Current or previous destruction of property endangering others 2. Threats (communicated by client or reported by others)  Threats of violence and client carries lethal weapon  Threats of violence and readily available and lethal method chosen  Threats of violence and there is a concrete plan with time and place set AND a foreseeable opportunity to commit the planned act of violence  Threats of violence and currently active psychosis combined with significant anger and agitation  Threats of violence and history of violence without provocation  Threats of violence and current alcohol/drug intoxication, especially amphetamines  Command hallucinations to commit violence  Threats of violence or other objective indicators of elevated risk of violence but mental status or lack of co-operation preclude adequate assessment If anyone factor present, consider risk serious; discuss with colleague Secondary Risk Factors: (Mediating) () Present () Absent (0) Unknown The following factors all significantly contribute to violence risk but are of a less critical nature. For the purpose of this instrument, all factors are considered of equal importance.  Male  Under 35 years of age  Police record of assaultive offences  Domestic violence history  History of mental illness, especially psychosis, organic brain syndrome, explosive disorder or antisocial personality  History of alcohol/drug use or dependency  History of parental brutality  Hypersensitivity to physical closeness (large "body buffer zone")  Hypersensitivity to challenges of one's masculinity (obviously for men only)  Fear of being closed in  Chronically low frustration tolerance, poor impulse control, accompanied by temper tantrums or rage reactions  Absence of empathy  Explosive appearance as subjectively judged  Presence of significant stressors (such as spouse threatening to leave, actual or suspected infidelity of spouse, job loss or business failure, provocation by others, etc)  Social isolation If seven ',/' or more, consider risk serious; discuss with colleague Risk Assessment (Violence Potential): Immediate Minimal Extreme Longer term Minimal Extreme Other Risks to Staff  Known presence of weapons  Association with violent acquaintances  Presence of savage pets  Known instability associated with drug use  Hostile family members ALERT: Risk Management:  Consultation sought from another staff member  Team advised  Collateral information obtained  Supportive/Key others informed Mitigating factors/strengths: Action Plan: (Consider: immediate intervention, hospital or community management, cognitive behavioural strategies, involvement of significant others, medication, mode of continuing treatment, consultant advice) _________________________________________________________________________________________________________________________________________________ Action Plan incorporated into and documented in Treatment Plan Physical Examination General Inspection: Wt (kg) _ Height Eye Colour Skin __ Dentition _ BP ___________ Pulse _ Temp ___ Resp Rate _ Head and Neck ____________________________________________________________________ Chest _ Abdo _ _____ CNS _ _ Other _________________________________________________________________________________________________________________________________________________________________________________________ Uninalysis _ _ General Health Concerns (review systems, check sleep, weight, appetite) _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Summary / Formulation: Brief summary of Presenting Problem, Illness, Past History and Mental State (MS E) and risk factors. _ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Investigations (record recent results if known, as well as tests ordered Initial Management Plan: Should note whether the patient requires psychiatric treatment at this time. If so, which target problems or symptoms the treatment is aimed at. What kind of treatment or combination of treatments the consumer should receive and what treatment setting seems most appropriate. Frequency of involvement, commencement date / times, mode, location, and type of therapy (eg. individual, family, group etc). Role of medication? Specific goals are noted. An estimation of length of treatment can be made. Note whether Voluntary or Involuntary treatment is required. _ Consultant Review (where appropriate) Subsequent Management Plan and Action (reviews, additional information and assessments, suggested engagement and management strategies. Sign entries, state role, date and time.) • Written in context and formatting of Initial Management Plan __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Discharge Planning and Community Management Considerations What needs to change to enable community management? Review initial presenting problems and management plans. Evaluate the relative success on resolving the problems, and impact Management Plans had on it. On considering this apply, where appropriate, what interventions were / are successful and what needs to be incorporated into the community management or discharge. Discharge planning should include early warning signs and indications for recontact. Referral information, Who? When? Where? Why? How? Notified? Appointment made? (by service or consumer initiated) needs to be noted. Consider: • family supports community supports _ • accommodation _____ • finances _ • legal matters _ • case manager • compliance • depot medication • special drug monitoring _ • Interim Detention Order (ITO) (inpatient or community) • guardianship/administration order child protection issues • mental state at discharge _ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________