Summary of Care

Name of Service

Phone:

Email:

 

NB: This is not the hospital discharge summary, and refers only to the psychiatric aspects of care provided.

 

Date Admitted:

Date Referred to CLPS:

Date Closed to CLPS:

 

Referral Source

 

 

Referral Reason

 

 

Psychiatric History

 

 

Mental Health Act status

+ add in a comment if the MHA was used during the admission

 

Voluntary

Recommendation for Assessment expires @

(the RA is the MHA2016 equivalent of R+R in MHA2000)

Treatment Authority

(the TA is the MHA2016 equivalent of ITO in MHA2000)

 

Substance Use

 

 

 

Medical/Surgical

 

This Admission

 

 

History

 

 

Medication Allergies

 

 

 

Key Contacts

 

 

 

 

Findings on Assessment

 

eg: a summary of psychiatric and psychosocial issues

+ what treatments/strategies worked + didn’t work?

+ results of any formal screening

+ copy of most recent mental state examination

 

DASS 21

 

Depression, Anxiety, Stress Scale (DASS 21) as at

Depression =

Anxiety =

Stress =

 

Cognitive Screening

 

+ include date(s) of screening

 

Mini-Mental State Examination (MMSE) =  /30

Frontal Assessment Battery (FAB) =  /18

Clock Drawing Test =  /10

Rowland Universal Dementia Assessment Scale (RUDAS) = /30

Montreal Cognitive Assessment (MoCA) =  /30

Adenbrooke's Cognitive Examination (ACE III)  = /100

Mental State Examination

 

Appearance -

Behaviour -

Speech -

Affect -

Mood -

Thought Form -

Thought Content -

Perception -

Cognition –

Insight -

Judgement -

 

Estimated Risk (on closure to CLPS)

 

Self -

Others -

Vulnerability -

Absconding -

 

Impression/Formulation

 

 

 

Axis I (Primary Psychiatric Diagnosis)

 

 

Axis II (Personality and Intellectual Disorders)

 

 

Axis III (General Medical Conditions)

 

 

Axis IV (Psychosocial and Environmental problems)

 

 

Recommended Management Plan

eg: scheduled appointments, medications, strategies, etc

+ who will be given a copy of this file entry?

 

1.

 

2.

 

3.

 

4.

 

5.

 

 

 

 

Name

Role

Service