Internal Code : MAS3993
From watching the Jonathon videos in weeks 2 and 3 and utilising the mental health Assessment prompts document. You are required to record a Mental State Examination on Jonathon Doeman. This is to be recorded on the provided template. It is acknowledged that all information required for this assessment may not be presented on the video and as a part of this assessment you must clearly identify what elements are missing or need to be further assessed.
Some things to remember when documenting clinically:
• There is no word limit and no references are required.
• keep your notes succinct
• your notes MUST be objective (see my notes further down to help with this)
• be mindful of your language choices, your notes must be free from judgement and bias
• They must be accurate, a lot of students last term wrote that Jonathon was malodorous and this cannot be observed from a video recording.
• Only include information that you are given in the videos.
• Keep your assessment person centred. The term Patient is not used in Mental Health and you will be docked for same. A suggestion if you must use his name ‘Jonathon’
Keeping your writing objective:
This can be challenging at the best of times but is an essential nursing skill regardless of what area you work in. In every clinical environment there will be times when you need to assess and document a consumer’s mental state. Doing so accurately will ensure that the person receives the 7 correct assessment and appropriate treatment. In mental health, incorrect documentation may lead to a person being detained against their will or receiving treatment against their consent. When assessing how a person feels or any internal stimuli they may be experiencing it is impossible to do this using observational skills. Therefore you need to document what the person tells you. To do this in an objective manner, you need to make it clear that you are writing what they tell you. Avoid summarising their information or forming a judgement when writing, use direct quotes or write that you have been told the information
Examples of this are:
- Jonathon states he feels tired. “Not good, not bad, just tired.”
- Jonathon reports that his alcohol intake has increased since he lost his job.