Assessment Analysis in Mental Health Service Delivery 1
Assessment Analysis in Mental Health
Nursing.
NURS 1087.
Assessment Task 2: A Comprehensive
Consumer Assessment.
Assessment Analysis in Mental Health Service Delivery 2
Assessment Task Number Two:
A Comprehensive Consumer Assessment
DUE: Due at the end of week 12 (Sunday 16th October) by 2359.
Title: 3000 Word Consumer Assessment 50 %
Assessment Task Number Two: Worth 50%
You are required to complete the following Consumer Assessment task.
This assessment task needs to be submitted by the end of Week 12 [October
16th]; submission deadline is 23:59 AEST (Australian Eastern Standard Time).
Please post any questions you have about the assignment in general on the
relevant course Discussion Board. If you have any questions specific to your
personal situation and the assignment please email the course coordinator as
required.
The Assignment should include a brief introduction that will provide an
outline of the assignment to follow. Any additional information deemed
relevant by the author should be included as an Appendix.
The assignment should be submitted through Turnitin available via the course
webpage from the beginning of Week 10 of semester 2 onwards.
Instructions on the Consumer Assessment Task:
You are required to complete the following consumer assessment task.
1. For the consumer assessment you are required to choose a consumer
from within your practice in the field of mental health nursing for your
assessment.
2. You should seek to choose a consumer with whom you will be able to do
more than one interview (or will have regular contact).
3. You are required to choose a consumer with whom you would already
have had regular contact in the course of undertaking your work as a
mental health nurse, and base your assessment upon any interactions
that you would normally have had with that consumer.
4. You are required to maintain the consumers confidentiality and
anonymity at all times (Id suggest you create a pseudonym for this).
Assessment Analysis in Mental Health Service Delivery 3
5. You are required to complete the consumer assessment by utilising:
Consumer Interviews
Case Notes
Other appropriate information sources
Please note, that information sourced must be noted / referenced
within your consumer assessment.
6. You will also be required to incorporate into your assignment any
appropriate consumer assessment tools such as the Suicide Rating Scale
and HoNOS that you have used. These can be same the tool(s) that you
have already critiqued as part of an earlier assessment if you would like
and are to be attached as an Appendix.
7. You are also required to undertake and journal your reflections on the
process of completing the assessment as you go along. You will then
include this as the final (separate) section of the assignment as a personal
reflection. This section is expected to be approximately 500 words in
size.
8. A Checklist and Example Format is included below for your use though
you can utilise a different structure for your assignment if would like to
do so. A Marking Guide is also included. If you decide to use a different
structure for your assignment please make sure that you have met all the
requirements of the marking guide.
9. As with the first Assessment Task you must support your writing with
appropriate references from the literature in areas such as [1] key
concepts and ideas, [2] skills utilised/ applied, [3] theoretical constructs
or models [4] symptoms and diagnoses, [5] communication strategies /
observations and [6] any other situations where your writing is based
upon prior literature
An Alternative Assessment Focus
Students that do not have access to mental health consumer are able to
undertake this consumer assessment assignment by developing a case study.
This can be based upon their [a] previous clinical experience, [b] personal life
or [c] a combination of the above.
If you wish to use this option please contact the Course Coordinator to
discuss the details.
Assessment Analysis in Mental Health Service Delivery 4
Assessment Task Two Assessment Section Checklist
No. Consumer Assessment checklist Included Not Included
Demographic Data:
Name of Mental Health Nurse Assessing Consumer
Date of Assessment
Consumers full name (pseudonym)
Consumers date of Birth (pseudonym)
Consumers gender (pseudonym)
Martial status
Consumers Address (pseudonym)
Consumers telephone number(s)
UR Number
Next of Kin / Contact person
Name address and contact phone numbers
Name of Referral Source
Name of any other worker or agencies involved
Presenting Complaint:
Why has the Consumer presented at this time?
What are the Consumers main concerns?
Are there any identifiable precipitating factors?
Past Psychiatric Treatment:
Admission
Year and type (voluntary Involuntary)
Diagnosis (if known)
Treatment employed (ie. ECT, Medication, Therapy,
etc).
Treating agencies (ie. Community Assessment
Teams, Hospitals, Clinics, Private Psychiatric)
Current Psychiatric Treatment:
Psychoactive medication
Therapies
Rehabilitation
Recovery Model Factors:
Strengths, abilities, capacity, resources?
Key relationships, community engagement.
Accommodation:
Type
Length of Stay
Problem associated with?
Assessment Analysis in Mental Health Service Delivery 5
Assessment Task Two Assessment Section Checklist (Cont)
No. Consumers Assessment checklist Included Not Included
Financial Arrangements:
Source of Income
Debts
Any Administration Orders?
History As Reported By Others:
Name of source
Relationship to Consumer
Family History:
GENOGRAM
Other family members psychiatric history
Dates and causes of death
Relationship descriptions between family members
(How does the Consumer and others view the
family)?
Personal History:
EARLY CHILDHOOD DEVELOPMENT
Problems encountered during the pregnancy by
mother
Birth (ie. prolonged labour, forceps delivery,
caesarean)
Developmental Milestones
Childhood social relations
Significant early life events
SCHOOL PROGRESSION
Progress
Levels of achievement v/s perceived level of
potential
Problems encountered (ie. truancy, bullying, etc)
OCCUPATIONAL HISTORY
First job
Number and type of jobs
Reasons for changing jobs
Unemployment (Length of time and effects on
Consumer and family)
RELATIONSHIPS / MARTIAL HISTORY
Psychosexual development
Current relationship with partner
Name and ages of children
Feelings towards children
No. Consumers Assessment checklist Included Not Included
DRUG AND ALCOHOL USE
Assessment Analysis in Mental Health Service Delivery 6
As reported by self and others
FORENSIC HISTORY /LEGAL MATTERS
Does the person have any legal proceedings
underway or pending?
Are there any legal restrictions or orders applying to
this person?
Does the person have a criminal record?
MEDICAL HISTORY
PERSONALITY
Self perception
Families perceptions of consumer
Changes
CULTURAL / SPIRITUAL ISSUES
Mental Status Examination:
GENERAL PRESENTATION
ORIENTATION
THOUGHT
Current
Stream
MOOD & AFFECT
PERCEPTUAL ABNORMALITIES
ATTENTION / CONCENTRATION
MEMORY
INSIGHT
JUDGEMENT
NEUROLOGICAL EXAMINATION
Risk Assessment:
Summary /overview of the consumers major risk
issues
Summary:
Summary /overview of the consumer identifying
major issues
Formulation: (Diagnostic)
According to DSM-5
Problem Definition:
Statement of problems to be addressed in
management plan
Reflective Journal: Mandatory
A descriptive exploration of your
experience of conducting the assessment.
Mandatory
Appendix:
Use of additional assessment tools to support
diagnosis
Appendix:

Assessment Analysis in Mental Health Service Delivery 7
Assessment Task Two Example Format:
Psychiatric Nurse Assessing:
Date:
Consumer Name (in full):
Date of Birth:
Sex: Male Female
Address:
Telephone Home:
Telephone Work:
UR Number _ _ _ _ _ _
Next of Kin Contact Person:
Name:
Relationship to the Consumer:
Address:
Contact Telephone Number Home:
Contact Telephone Number Work:
REFERRAL SOURCE:
OTHER WORKERS / AGENCIES INVOLVED
Assessment Analysis in Mental Health Service Delivery 8
Assessment Task Two Example Format (Cont)
PRESENTING COMPLAINT:
PAST PSYCHIATRIC TREATMENT:
CURRENT PSYCHIATRIC TREATMENT:
ACCOMMODATION:
FINANCIAL ARRANGEMENTS:
HISTORY AS REPORTED BY OTHERS:
FAMILY HISTORY: GENOGRAM
RECOVERY ENGAGEMENT / RESOURCES / RELATIONSHIPS:
Assessment Analysis in Mental Health Service Delivery 9
Assessment Task Two Example Format (Cont)
PERSONAL HISTORY:
EARLY CHILDHOOD DEVELOPMENT
SCHOOL PROGRESSION:
OCCUPATIONAL HISTORY:
RELATIONSHIP / MARTIAL HISTORY:
DRUG AND ALCOHOL USE:
FORENSIC HISTORY / LEGAL MATTERS:
MEDICAL HISTORY:
PERSONALITY:
Assessment Analysis in Mental Health Service Delivery 10
Assessment Task Two Example Format (Cont)
CULTURAL BACKGROUND:
SPIRITUAL CONSIDERATIONS:
GENERAL PRESENTATION:
ORIENTATION:
THOUGHT
Content:
Stream:
MOOD & AFFECT:
PERCEPTUAL ABNORMALITIES:
ATTENTION / CONCENTRATION:
Assessment Analysis in Mental Health Service Delivery 11
Assessment Task Two Example Format (Cont)
MEMORY:
INSIGHT:
JUDGEMENT:
RISK ASSESSMENT:
SUMMARY:
FORMULATION (Diagnostic):
PROBLEM DEFINITION & INITIAL MANAGEMENT PLAN
Assessment Analysis in Mental Health Service Delivery 12
Reflective Journaling Section:
Once you have completed the Comprehensive Assessment part of the assignment you are
then required to complete a Reflective Journaling section as the last part of this Assessment
task. This reflection needs to be more than a simply descriptive summary of your
experience of the assessment process and equally it shouldnt be a scorecard reporting on
how well you think you did. You need to take a step back from the clinical process of
undertaking this assessment and consider the personal experience that occurred.
There are many different ways to approach this (and there is no one right way) so you
have a great deal of choice in how you complete this section. Ive included some (entirely
optional) sample questions below to ask yourself to get the reflective process started. These
arent intended to be answered Q & A style; theyre there to get the creative juices flowing.
What were my expectations going into the assessment interaction?
Where was my headspace at going into the assessment interaction?
What personal / emotional factors were influencing me going into
the assessment interaction?
What contextual factors were influencing me going into the
assessment interaction?
What contextual factors were influencing the consumer going into
the assessment interaction?
What corporate / institutional factors did I notice occurring during
the assessment interaction?
What thoughts / emotions did I notice occurring during the
assessment interaction?
Did I notice any strong personal (cognitive / emotional) responses
during the assessment interaction?
What influence did my question (to the consumer) and broader
communication have upon the assessment interaction?
How comfortable did I feel during the assessment interaction?
Did I experience any uncertainty / apprehension / anxiety during
the assessment interaction?
Do I feel like I was able to empathise with the consumer?
Do I feel like I got a real sense of this persons unique lived world
experience / perspective?
If I could have my time over, what changes might I make to what I
did / did not do during the assessment interaction?
These are these to stimulate reflection not restrict it so please use or discard at
your own discretion.
Assessment Analysis in Mental Health Service Delivery 13
Assessment Task Two Marking Guide:
Assignment Content
Mark
Mark
Awarded
Marker Comments
1. Presenting complaint /2 /2
2. Past psychiatric treatment /2 /2
3. Current psychiatric treatment /2 /2
4.
Living, financial and occupational
status
/2 /2
5. Family history /2 /2
6. Personal history /3 /3
7. Recovery Engagement /3 /3
8. Mental status Examination /8 /8
9. Risk Assessment /5 /5
10. Summary /3 /3
11. Problem definition /3 /3
12. Reflective Journaling /10 /10
13. Appendices and referencing /5 /5
Total Mark /50 /50