qc9 critical components of risk assessment and management

QC9 Critical Components of Risk Assessment and Management

Information for Assessment

Please read the following information in relation to Jarred prior to completing the assessment. This clinical documentation accompanies the video of the clinical interview with Jarred, and the audio of the phone call with Jarred’s mother.

Jarred Wati

• Primary diagnosis: Bipolar affective disorder ICD-10 code F31.00• Secondary diagnosis: Amphetamine-type substance use disorder ICD-10 code

F15.2.

The following documents are included

• Part of Jarred’s most recent General Mental Health Assessment (not including riskscreen or formulation)

• Jarred’s current Recovery Plan.

Important notes on dates

Dates have been provided in a format to ensure currency for assessment purposes only. In practice, all dates (including dates of birth) should be written in full, using the DD/MM/YYYY format.

For your assessment, consider that the interview has occurred on the date that you are submitting the assessment.

Version 1 - 15/07/2019

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Mental Health ServicesGeneral Assessment

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Does the consumer have an Advance Health Directive? Y N UK An interpreter was used

Reason for referral (include whether consumer and carer are aware of, and in agreement with, the referral)

History of presenting problems (consider onset, precipitant, major symptoms, impact of cultural/spiritual issues, interventions attempted and effectiveness of attempts)

Psychiatric history (consider self harm and suicide attempts, treatment for substance use, co-morbidities)

Forensic history and current legal issues

Mental Health Act statusNone Forensic order (mental health) Treatment support order Transfer recommendation

Examination authority Person AWA (interstate) Classified (involuntary) Examination/judicial order

Conditions of order:

Forensic order (disability)Forensic order (criminal code) Recommendation for assessment

Treatment authorityClassified (voluntary)

Instruction: this assessment must include consideration of collateral information.

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Date of birth: Sex: M F IFacility: .........................................................................................................

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Physical health (include medical conditions and treatments, weight, diet, exercise. Note relevant investigations and interventions and the results of these)

Consumer requires metabolic monitoring

Previous medications (include any side effects and reason for cessation. Register alerts for allergies or adverse reactions in CIMHA)

Current medicationsDrug name (include prescribed and complementary medicine)

Duration of use

Dose and special directions (such as route/injection site)

Prescribed by

Developmental history (consider pregnancy, birth and early developmental milestones, attachment/separation issues, educationhistory, social relationships, recreational activities, sexuality and/or gender identity, any significant life events, stress and trauma)

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Family history (consider family mental health and/or substance use history, illnesses or disabilities, family/carer relationships (extended and immediate), employment and other relevant cultural aspects)

Current functioning and practical issues (note strengths and weaknesses. Also consider cultural supports, accommodation issues, if the consumer is a carer for a child/parent/other)

Consumer requires a functional assessment Consumer requires a cognitive assessment

Mental state examinationGeneral appearance and behaviour

Speech (include rate, volume and tone)

Mood and affect (include range, appropriateness, congruence with mood and communication)

Perception (include hallucinations and illusions)

Thought form/flow (logical, tangential, blocked, concrete)

Thought content (include delusions, suicidal ideation, thoughts alienation and passivity experiences, phobias and obsessions)

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Judgement

Cognitive assessment (include orientation, memory and capacity)

Substance use and addictive behaviours (WHO ASSIST v3.0)Q1 ASK CONSUMER: In your life, which of the following substances have you ever used: No Yes

a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)

b. Alcoholic beverages (beer, wine, spirits, etc.)

c. Cannabis (marijuana, pot, grass, hash, etc.)

d. Cocaine (coke, crack, etc.)

e. Amphetamine type stimulants (speed, base, ice, crystal, Shabu, MDMA, ecstacy, etc.)

f. Inhalants (nitrous, glue, petrol, aerosols, paint thinner, etc.)

g. Sedatives or sleeping pills (Valium, Serepax, Xanax, Rohypnol, etc.)

h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)

i. Opioids (heroin, morphine, methadone, codeine, etc.)

j. Other (e.g. synthetics, steroids, etc.) specify:

If “No” to all items, continue to next section.If “Yes” to any items above, ask Question 2 for each substance ever used.

For repeat assessments, compare answers provided to previous screens. Any differences should be queried.

Q2 ASK CONSUMER: In the past three months, how often have you used the substances you mentioned before (first drug, second drug, etc.)?

NeverOnce or

twiceMonthly Weekly

Daily oralmost daily

a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)

b. Alcoholic beverages (beer, wine, spirits, etc.)

c. Cannabis (marijuana, pot, grass, hash, etc.)

d. Cocaine (coke, crack, etc.)

e. Amphetamine type stimulants (speed, base, ice, crystal, Shabu, MDMA,ecstacy, etc.)

f. Inhalants (nitrous, glue, petrol, aerosols, paint thinner, etc.)

g. Sedatives or sleeping pills (Valium, Serepax, Xanax, Rohypnol, etc.)

h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)

i. Opioids (heroin, morphine, methadone, codeine, etc.)

j. Other (e.g. synthetics, steroids, etc.) specify:

Comments (consider other issues such as gambling, intoxication and/or at risk of withdrawal, motivation for change)

Consumer is currently receiving specialised treatment for substance use

Insight (understanding of illness)

If any substances in Q2 were used in the previous three months, a Substance Use Assessment must be completed.

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MY R

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VERY PLAN

If you do not have enough room, please attach more pages at the end.

This is who I am - my characteristicsThese are my strengths:

Things I would like to strengthen:

What I do to keep well?

What have I done in the past?

My early warning signs / triggers?

What I have done to manage these in the past?

What have I done in the past that hasn’t worked?

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(Affix identification label here)

URN:

Family name:

Given name(s):

Address:


My Recovery Plan

Facility: .........................................................................................................

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These are my goals - what I want to do and where I want to beSocial: • Myhousingneeds • Mysocialactivities(e.g.hobbies,sports,shopping,eatingout)

• Mylivingskills • Myfinancesandbudgeting

Emotional:• Myrelationships(e.g.partner,children,siblings,parents,carer,friends,boss/workmates,pets)• If Iamnothome,whowilltakecareof:mychildren/family;mymedication;themail;thenewspaper;mypets;thewheeliebins• Mysupportnetworks(e.g.NGO,GP,MHS,localgroup,other[specify:....................................................................................................................................])

Physical: • Myphysicalhealthandwell-being(e.g.sport,gym,doctorappointments, • Mypersonalcaredental,complementary/alternativetherapies,preferredmedications)

Intellectual: • Mywork • Mystudy • Myvolunteering • Reading • Othersocialoutlets(e.g.trivianight,chessclub)

Spiritual: • WhatIdotokeepmyself wellspiritually(e.g.meditation/prayer,practices)

People I would like involved in my care:Name: Relationshiptome: Contactdetails:

Name: Relationshiptome: Contactdetails:

People to contact in an emergency:Name: Relationshiptome: Contactdetails:

Name: Relationshiptome: Contactdetails:

How they can best help me:

IconfirmthatthisismyRecoveryPlan,andacknowledgethatIunderstandmyroleandtheroleof otherpersonslistedinthePlan.IamalsoawarethatIcanrequestachangetothegoalssetdownif theyarenotmeetingmyneedsbydiscussingthiswithmynominatedsupportstaff.

I have received contact details and know how to contact my support staff

I have been provided with mental health crisis numbers

I was involved in developing this plan and have received a copy. SignedbyPersoninRecovery:

I assisted in the development of this Plan. SignedbyCarer:

I assisted in the development of this Plan. SignedbyClinician:

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(Affix identification label here)

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My Recovery Plan

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qc9 critical components of risk assessment and management

Documents