Mental health assessment and intervention report
Length: 1500 words ± 10%
Weight: 60%
Task:
This assignment requires you to watch the interview provided in the Case study video below titled "Psychiatric interviews for teaching: Psychosis to complete a mental health assessment and intervention report. In your report ensure to:
· Refer to the diagnostic criteria as listed in the DSM-5 (American Psychiatric Association, 2013) to validate your decision that the client has a psychiatric disorder.
· Support your report by providing evidence from the case study video.
· Provide evidence that you have thought about the mental health nursing practice by examining your thinking about your decisions, observations and recommendations.
· Use the Assessment 1 Marking Guide Criteria to guide you about aspects of presentation.
·
Link for the video=
· https:
youtu.be/ZB28gfSmz1Y
Guidelines for writing your report
The report has three sections:
· Part A is an assessment of the client's psychiatric history and family/social environment;
· Part B is a mental state examination;
· Part C is evidence-based interventions.
Instructions
You will need to view the case study video and during the video make notes on the items listed for Parts A, B and C below:
Part A: History (20 marks)
Part B: Mental state examination
(20 marks)
Part C: Care Plan (20 marks)
Reason for refe
al
History of presenting problem
Past psychiatric/mental health history
Medical history
Family history
Personal history
Occupation history
Forensic history
Drug and alcohol history
Cu
ent treatments
Cu
ent functioning and supports
Parental status and/or carer responsibilities
Details of dependents
Appearance
Behaviou
Affect
Mood
Speech
Thought form
Thought content
Perception
Cognition/intellectual functioning
Insight and Judgement
Risk assessment
Formulation
Provisional diagnoses
Need for refe
al
1. Medical intervention
(Clinical issue/ goal)
2. Psychosocial intervention
(Clinical issue/ goal)
3. Nursing intervention
(Nursing diagnosis/goal/interventions)
Report presentation
The Mental health assessment and intervention report should be well planned.
For this assessment it is important for you to:
· Outline your introduction clearly and end with a concise conclusion.
· Make sure you justify your report by refe
ing to what was said during the interview.
· Write in complete sentences (i.e. do not use dot points).
· Address the points in Part A as a single section using complete sentences without using sub-headings.
· Use the points in Part B as sub-headings to structure Part B of your report.
· Make sure each sentence only deals with one issue. Keep sentences short, professional and to the point.
· In Part B the "formulation" section provides a summary of the information contained in the previous sub-sections. New information should not be placed in this section. If it is not in the body of a report it should not be in the formulation section.
· Does the client need to be refe
ed to a psychiatrist? Why?
· Pay attention to spelling, grammar and punctuation. It is important to proof read your work before submission.
· Writing style in a report is more formal than ve
al speech. Try not to write as you would speak.
· Use simple past tense to describe the patient's state at the time of the mental state examination. This emphasizes that the examination findings are specific to the time of conducting the interview.
After you have completed Parts A and B you can start Part C.
Part C requires you to research the mental health literature and recommend three evidence-based interventions to assist the client.
· Discuss each intervention separately and use a sub-heading so that the reade
marker know the intervention being discussed.
· What is the goal for the intervention?
· What is the clinical issue being addressed by each intervention?
· Ensure the three interventions you select are consistent with evidence-based treatment guidelines.
· Justify your decision by refe
ing back to evidence-based literature.
· Make sure you appropriately reference your work using in-text references to support any statement of fact.
· Include a reference list on a separate page at the end of the report.
· video in this assessment. For Part B, you are required to use the MSE categories as subheadings. There are no specific number of references per section of the essay but the minimum. For Part C you may use subheadin
· Essentially PART A is a collation of findings we have discovered from the video and presented in essay format, not dot point. Are we to ONLY reference the video in this because we are not using another other sources?
· Part B we are to use sub- headings of the MSE categories provided and state what evidence the video showed of these different sub headings, how many references are required for this part?
· And Part C is where we identify treatment/ management, do we use sub headings here?
· Are we also to use sub headings throughout, eg 'Part A' as a heading?
Write nursing intervention in na
ative format
Use the different elements of the MSE as subcategories for Part B. For Part A, focus on presenting the patient history and not medical analysis. For example, instead of saying auditory hallucinations, you can just say Andy stated that he has been hearing voices for a certain time frame.