Implementation guidelines for private office based mental health practices

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

  • carers' support available 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 services

  • crisis intervention plan

  • options for treatment setting (whenever 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. Top of page

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 the use of culturally appropriate assessment tools and methods used.

Because there are many clients with alcohol, tobacco and other drug (ATOD) problems, services could benefit from the administration of a self-audit baseline assessment, such as COMPASS, to address co-morbid ATOD issues in a more comprehensive, integrated way. A further self audit could be carried out after, for example, 12 months. Services could also benefit from 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 and/or the carer.

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, the planning is more efficient. Sufficient time to communicate and consult with relevant stakeholders, such as the consumer, carer and other health care professionals will facilitate continuity of care following discharge.

Review (Criteria 10.4.5, 10.4.6)

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

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

Evidence of assessment review is recorded in the consumer's individual health record.

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

Follow-up (Criterion 10.4.7)

Risk assessment is conducted and documented for people who decline to participate in an assessment and an appropriate form of contact is planned with the referring agent. Support is offered to carers when relevant.

Interdisciplinary care plan (Criterion 10.4.8)

The treatment, care and recovery plan is developed with input from the consumer, carers, the person responsible for the coordination of care and other service providers. It should contain the details of treatment provided and expected outcomes to meet the consumer's individual needs, provide continuity of care and complement treatment, care and recovery plans developed by other service providers.

Existing carers' relationships and the capacity, willingness and needs of the carers should be considered when developing the treatment, care and recovery plan so that the necessary supports are for the consumer are established.

The MHS should be able to provide evidence that the consumer and their carers 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 carers.

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.Top of page

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:
    • follow-up procedures
    • assessments including risk assessments
    • development of treatment, care and recovery plans.