Implementation guidelines for public mental health services and private hospitals

10.4 Assessment and review

Page last updated: October 2010

Consumers receive a comprehensive, timely and accurate assessment and a regular review of progress is provided to the consumer and their carer(s).

Guidelines
Suggested evidence

Guidelines

The intent of this Standard is to ensure that the mental health service (MHS) provides evidence that appropriate information is collected, reviewed and recorded in the individual consumer's health record as part of the assessment, review, treatment and recovery process.

Examples of appropriate information include:
  • history of previous mental health problems
  • medical history
  • details of present health
  • functional and emotional status, including the consumer's ability to communicate and care for themselves
  • cultural and social history and cultural formulation of diagnosis when required
  • level of risk the consumer presents to themselves and others
  • the consumer's perception of their needs, desired outcomes and their expectations of service delivery
  • details of available carer support after the consumer exits the MHS
  • consumer's knowledge of how to maintain a healthy lifestyle and reduce the risk of mental health problems
  • consumer's economic situation, social circumstances and level of education
  • individual needs of the consumer and carers that may affect service delivery
  • diagnosis
  • education about the disease
  • range of treatments available
  • information about alcohol, tobacco and other drug (ATOD) services
  • crisis intervention plan
  • available treatment settings (wherever possible treatment should be administered in a setting of the consumer's choice)
  • evaluation of treatment options
  • treatment consent forms signed by the consumer and appropriate MHS staff
  • details of integration of care with other providers
  • service exit plan.
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Assessment tools and methods (Criterion 10.4.1)

Assessment tools and methods appropriate to the individual MHS include diagnosis, functional assessment, family input, suicide and other risk assessment, problem-oriented assessment, formulation and mental status examination. The MHS should be able to provide evidence of using culturally appropriate assessment tools and methods.

Owing to the high rates of clients with ATOD concerns, services could benefit from using a self-audit baseline assessment such as COMPASS, to address co-morbid ATOD issues in a more comprehensive, integrated manner. A further self audit could be carried out after 12 months, for example. Services could also benefit from using a validated screening tool related to ATOD use.

Conduct of assessments (Criteria 10.4.2, 10.4.3)

Evidence that assessments are conducted during the consumer's first contact with the MHS is recorded in the consumer's individual health record. There should be evidence of who was involved, including other service providers or the carer.

The consumer's preferred setting for assessment could be a home visit rather than in the community mental health centre, emergency department or psychiatric unit. The MHS may use the telephone or video to conduct assessments in situations where face-to-face assessment is not possible due to distance or the consumer's preference.

The MHS should consider using, and documenting, the use of an interpreter, particularly in remote Indigenous settings. Collateral informants should regularly be consulted and their use documented.

Information on informed consent is available in the guidelines for Standard 1 Rights and responsibilities.

Planning discharge (Criterion 10.4.4)

When discharge planning begins early in the admission to inpatient care, the planning is more efficient. Time to communicate and consult with the consumer, the carer and other health care professionals will facilitate continuity of care after the consumer is discharged.

Discharge planning for Indigenous clients must involve inpatient staff, relevant outpatient MHS staff, representatives of the primary care service in the community to which the consumer will return and relevant carers or family.

Review (Criteria 10.4.5, 10.4.6)

Assessment is reviewed regularly. A complete assessment depends on many factors, such as the type or complexity of the services provided, so information should be updated regularly.

Crisis intervention should be included in treatment, care and recovery plans both for this episode and for future presentations.

Evidence of an assessment review should be recorded in the consumer's individual health record.

Information on risk assessment is provided in the guidelines for Standard 2 Safety.

Follow-up (Criterion 10.4.7)

Risk assessment is conducted and documented for people who decline to participate in an assessment. An appropriate form of contact is planned with the referring agent and support is offered to carers where relevant.Top of page

Interdisciplinary care plan (Criterion 10.4.8)

The treatment, care and recovery plan is developed with input from the consumer, carer, the person responsible for the coordination of care and other service providers. It should contain the details of treatment provided and the expected outcomes. It should ensure continuity of care and complement treatment, care and recovery plans developed by other service providers. The plan should be consistent with the consumer's culture and education. Involvement of carers or cultural brokers should be documented.

Existing carer relationships and the capacity, willingness and needs of the carer should be considered when developing the treatment, care and recovery plan. This ensures that the necessary supports are put in place for the consumer.

The MHS should be able to provide evidence that the consumer and their carer have received a copy of the current treatment, care and recovery plan and that steps have been taken to ensure that the content of the treatment, care and recovery plan is understood by the consumer and their carer.

The age of consumers and carers will affect the degree to which they are involved in the development of their care and recovery plans. Care and recovery plans should be age appropriate especially where there are young carers. Child and adolescent consumers who experience problems within their family may have a legal guardian or others involved in their care and support who may need to be involved in the care plan.

The consumer participates fully in the development of the individual treatment, care and recovery plan and in the evaluation of outcomes.

Suggested evidence

Evidence that may be provided for this standard includes:
  • assessment methods and tools
  • health record review of treatment, care and recovery plans
  • consumer survey results
  • policies and procedures covering:
    • follow-up procedures
    • assessments, including risk assessments
    • development of treatment, care and recovery plans
    • appropriate culturally adapted protocols and resources.