Form Template A4 Standard
Total Page：16
File Type：pdf, Size：1020Kb
MHT 36 Secure Extended Care Unit Report Local Patient Identifier
FAMILY NAME
GIVEN NAMES
DATE OF BIRTH SEX Mental Health Statewide UR Number Place patient identification label (if available)
Patient’s name: Click here to enter text. Start date of current period of compulsory treatment: Click here to enter a date. Date of current Treatment Order| From: Click here to To: Click here to enter a enter a date. date. Date of SECU admission: Click here to enter a date. Consultant Psychiatrist: Click here to enter text. Medical Officer: Click here to enter text. Case Manager (or equivalent role): Click here to enter text. Tribunal hearing date: Click here to enter a date.
Please read the instructions and guidelines to preparing Tribunal reports available online before completing this report.
Are you applying to withhold any documents from the Choose an item. patient? If ‘Yes’, complete form MHT30 Application to deny access to documents under section 191 of the Mental Health Act 2014 and send it to the Tribunal
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MHT 36 Secure Extended Care Unit Report Local Patient Identifier
FAMILY NAME
GIVEN NAMES
DATE OF BIRTH SEX Mental Health Statewide UR Number Place patient identification label (if available)
Part One: Background information
1.1 Give details of the patient’s cultural background. If the patient was not born in Australia, specify their year of arrival, first language and level of English proficiency. Click here to enter text.
1.2 Summarise the patient’s social circumstances prior to SECU admission. Include accommodation, employment, financial details, social stressors, relevant family and developmental history (include any childhood diagnoses and traumatic events). Click here to enter text.
1.3 What are the patient’s interests, activities, abilities and skills? Refer to before and during SECU admission. Click here to enter text.
1.4 Describe the patient’s current engagement in activities (including rehabilitation) and routines in SECU and the community. Describe the patient’s ability with their activities of daily living.
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MHT 36 Secure Extended Care Unit Report Local Patient Identifier
FAMILY NAME
GIVEN NAMES
DATE OF BIRTH SEX Mental Health Statewide UR Number Place patient identification label (if available)
Click here to enter text.
1.5 Detail any alcohol or substance use issues. Describe how these issues impact on the patient’s mental health. Click here to enter text.
1.6 Detail other relevant medical issues and relevant history. Include any known organic brain disorder, intellectual disability or other serious health concerns. Describe how these issues impact on the patient’s mental health. Click here to enter text.
1.7 List all current medications (psychotropic and general). How long has the current treatment regime been in place? Give details about the most recent changes to medication. Click here to enter text.
1.8 List all relevant legal matters (such as VCAT or guardianship orders, court orders, and police and forensic matters). List historic and current matters using dates where possible. Click here to enter text.
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MHT 36 Secure Extended Care Unit Report Local Patient Identifier
FAMILY NAME
GIVEN NAMES
DATE OF BIRTH SEX Mental Health Statewide UR Number Place patient identification label (if available)
1.9 How long has the current treating team been treating the patient? Click here to enter text.
1.10 If the patient was transferred from another mental health service, which service made the referral? How long had they been treating the patient prior to SECU admission? Describe the involvement of the referring service in current treatment planning. Click here to enter text.
Part Two: Criteria for compulsory treatment
Section 5(a) – the person has mental illness. Section 4 defines mental illness as a medical condition that is characterised by a significant disturbance of thought, mood, perception or memory.
2.1 What is the patient’s current diagnosis? Has the patient received a different diagnosis in the past? If so, please provide details. Click here to enter text.
2.2 What information about the diagnosis has been given to the patient?
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MHT 36 Secure Extended Care Unit Report Local Patient Identifier
FAMILY NAME
GIVEN NAMES
DATE OF BIRTH SEX Mental Health Statewide UR Number Place patient identification label (if available)
Click here to enter text.
2.3 Summarise the patient’s psychiatric history (in chronological date order). Specify periods of compulsory and voluntary treatment. Consider the pattern of the patient’s illness, pre-morbid mental state and functioning, initial presentation/first episode, severity of relapse and precipitants, recovery and response to treatment. Click here to enter text.
2.4 Why was the SECU referral made? Give details regarding the circumstances leading up to the admission. What are the goals of the SECU admission? Click here to enter text.
2.5 Has there been a change in the patient’s mental state since the admission to SECU? Are the goals stated in question 2.4 being achieved? Click here to enter text.
2.6 When was the patient’s last psychiatric and physical review? Describe the findings of those reviews. Click here to enter text.
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MHT 36 Secure Extended Care Unit Report Local Patient Identifier
FAMILY NAME
GIVEN NAMES
DATE OF BIRTH SEX Mental Health Statewide UR Number Place patient identification label (if available)
Definition of mental illness
The next four questions address the definition of mental illness in section 4 of the Act. In answering these questions, you must include details and evidence upon which this assessment is based. Include the source of that evidence and how recently it was observed or occurred (use dates where possible). Describe current symptoms and symptoms that may have responded to treatment that are no longer evident. Refer to negative as well as acute/positive symptoms.
2.7 Does the patient have a medical condition characterised Choose an by a significant disturbance of thought (form or content)? item. Click here to enter text.
2.8 Does the patient have a medical condition characterised Choose an by a significant disturbance of mood? item. Click here to enter text.
2.9 Does the patient have a medical condition characterised Choose an by a significant disturbance of perception? item. Click here to enter text.
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MHT 36 Secure Extended Care Unit Report Local Patient Identifier
FAMILY NAME
GIVEN NAMES
DATE OF BIRTH SEX Mental Health Statewide UR Number Place patient identification label (if available)
2.10 Does the patient have a medical condition characterised Choose an by a significant disturbance of memory? item. Click here to enter text.
2.11 What views or explanations has the patient expressed about the matters discussed in questions 2.7 to 2.10? Click here to enter text.
Section 5(b) – because the person has mental illness, the person needs immediate treatment to prevent serious deterioration in the person's mental health or physical health or serious harm to the person or serious harm to another person.
You must include details and evidence upon which this assessment is based. Include the source of that evidence and how recently it was observed or occurred (use dates where possible).
2.12 Does the patient need immediate treatment to prevent Choose an serious deterioration in their mental health? item. Click here to enter text.
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MHT 36 Secure Extended Care Unit Report Local Patient Identifier
FAMILY NAME
GIVEN NAMES
DATE OF BIRTH SEX Mental Health Statewide UR Number Place patient identification label (if available)
2.13 Does the patient need immediate treatment to prevent Choose an serious deterioration in their physical health? item. Click here to enter text.
2.14 Does the patient need immediate treatment to prevent Choose an serious harm to himself/herself? item. Click here to enter text.
2.15 Does the patient need immediate treatment to prevent Choose an serious harm to others? item. Click here to enter text.
2.16 What views or explanations has the patient expressed about the matters discussed in questions 2.12 to 2.15? Click here to enter text.
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MHT 36 Secure Extended Care Unit Report Local Patient Identifier
FAMILY NAME
GIVEN NAMES
DATE OF BIRTH SEX Mental Health Statewide UR Number Place patient identification label (if available)
Section 5(c) – the immediate treatment will be provided to the person if the person is subject to a Treatment Order. Section 6 defines treatment for mental illness as things done, in the course of the exercise of professional skills, to remedy the mental illness or to alleviate the symptoms and reduce the ill effects of the mental illness.
2.17 What immediate treatment does the patient require? What is the patient’s current treatment and recovery plan? Please attach treatment/recovery and behavioural management plans. Click here to enter text.
2.18 How has the patient responded to current treatment? How is the patient expected to respond to the treatment? Click here to enter text.
2.19 Describe the beneficial and adverse effects of the patient’s treatment and provide details of how any side effects are being addressed. Click here to enter text.
2.20 Are there any treatment changes being contemplated and/or has alternative treatment been proposed? Please provide details.
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MHT 36 Secure Extended Care Unit Report Local Patient Identifier
FAMILY NAME
GIVEN NAMES
DATE OF BIRTH SEX Mental Health Statewide UR Number Place patient identification label (if available)
Click here to enter text.
Section 5(d) – there is no less restrictive means reasonably available to enable the person to receive the immediate treatment.
This criterion involves an assessment of whether the patient can receive treatment voluntarily rather than compulsorily. This criterion is not about treatment setting (i.e. inpatient or community), which is addressed further below.
2.21 What are the patient’s treatment and rehabilitation preferences and recovery goals? Include the patient’s preferences about accessing additional supports, services, etc. Attach any Advance Statement. Click here to enter text.
2.22 Has the patient participated in decisions about their treatment and/or treatment and recovery planning? How has the patient’s Advance Statement and other views and preferences been implemented or otherwise been taken into account? Click here to enter text.
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MHT 36 Secure Extended Care Unit Report Local Patient Identifier
FAMILY NAME
GIVEN NAMES
DATE OF BIRTH SEX Mental Health Statewide UR Number Place patient identification label (if available)
2.23 Have there been any issues around the patient’s adherence with treatment during the current admission? If so, describe the issues. Click here to enter text.
2.24 Describe the changes or strategies that need to occur in order for the patient to be treated less restrictively. (This may include things that the patient needs to do, supports that need to be put in place or strategies to address non-adherence or further assessments that need to be undertaken.) What steps are the treating team taking to support these changes or strategies? Have these changes and strategies been discussed with the patient? Click here to enter text.
2.25 Has the patient been treated as a voluntary patient in the past? Refer to any adherence issues. Click here to enter text.
2.26 Are there any leave arrangements in place? What has happened during leave? Click here to enter text.
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MHT 36 Secure Extended Care Unit Report Local Patient Identifier
FAMILY NAME
GIVEN NAMES
DATE OF BIRTH SEX Mental Health Statewide UR Number Place patient identification label (if available)
2.27 Provide details of key relationships, social connections and other services (e.g. Mental Health Community Support Services, general practitioner, private psychiatrist, carer, family, friend/s, guardian, nominated person, government and non-governmental departments, agencies or services (including drug, alcohol and occupational programs) involved or that need to be involved. Describe the patient’s acceptance of the involvement of these in their care, treatment and support. Include whether the patient has had the opportunity to work with an advocate, consumer support service or legal representative. Click here to enter text.
Setting and duration of proposed Treatment Order
2.28 What is the proposed treatment setting of the Treatment Choose an Order and why? If inpatient treatment is proposed, explain item. why treatment cannot occur within the community. Click here to enter text.
2.29 Has the patient been successfully treated in less restrictive environments in the past? If so, describe those circumstances. Click here to enter text.
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MHT 36 Secure Extended Care Unit Report Local Patient Identifier
FAMILY NAME
GIVEN NAMES
DATE OF BIRTH SEX Mental Health Statewide UR Number Place patient identification label (if available)
2.30 What is the proposed duration of the Treatment Order? Give details as to why the duration is proposed. How much of this time does the treating team anticipate the patient will be in SECU? Click here to enter text.
Part Three: Transition planning
In this part, the Tribunal would like to know about the treating team’s plan to transition the patient out of SECU and matters that will assist the Tribunal to conduct solution-focused hearings.
3.1 TRANSITION AND DISCHARGE PLANNING Are there any transition plans or discharge plans? Describe what needs to be done before transition or discharge (e.g. accessing funding packages or resources). What are the obstacles to discharge and what is being done to overcome them? Who will be the receiving service? Please summarise the details of communications with the receiving service. Click here to enter text.
3.2 TRIBUNAL HEARINGS
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MHT 36 Secure Extended Care Unit Report Local Patient Identifier
FAMILY NAME
GIVEN NAMES
DATE OF BIRTH SEX Mental Health Statewide UR Number Place patient identification label (if available)
Have steps or plans put forward at the last Tribunal hearing been carried out as anticipated? If not, give details as to why. If there is a further hearing, should the Mental Health Tribunal implement any strategies to enable hearings to be better used as a forum to monitor progress and define steps toward less restrictive treatment (e.g. through inviting other persons such as the patient’s support persons and representatives from other agencies or services)? Click here to enter text.
3.3 Are there any other relevant issues that you have not discussed above? Click here to enter text.
Part Four: Carer, family, nominated person’s views
4.1 If the patient is being supported by a carer, family, friend/s, guardian, or nominated person, please list their names and relationship to the patient. Has the patient’s diagnosis been discussed with those persons? Click here to enter text.
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MHT 36 Secure Extended Care Unit Report Local Patient Identifier
FAMILY NAME
GIVEN NAMES
DATE OF BIRTH SEX Mental Health Statewide UR Number Place patient identification label (if available)
4.2 If the patient’s carer/ family/ nominated person has expressed views about the patient’s treatment and/or Treatment Order, please provide details of their views (including whether these views can be complied with). Describe their involvement in the patient’s care, including whether they have regular contact with the patient. Click here to enter text.
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MHT 36 Secure Extended Care Unit Report Local Patient Identifier
FAMILY NAME
GIVEN NAMES
DATE OF BIRTH SEX Mental Health Statewide UR Number Place patient identification label (if available)
AUTHOR OF THE REPORT
Signed: Print Click here to enter text. Date of Report: Click here to name: enter a date. Length of time you have known the Click here to enter text. patient: Date you last reviewed the patient: Click here to enter a date. Date the patient was given a copy of Click here to enter a date. this Report: If more than one person has authored the Report, please list their names and positions: Click here to enter text.
CONFIRMATION OF REPORT BY AUTHORISED PSYCHIATRIST I have reviewed and confirm the accuracy of this report.
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MHT 36 Secure Extended Care Unit Report Local Patient Identifier
FAMILY NAME
GIVEN NAMES
DATE OF BIRTH SEX Mental Health Statewide UR Number Place patient identification label (if available)
Signed: Authorised psychiatrist/ delegate Print Click here to enter text. Date: Click here to enter a name: date. Date you last reviewed the patient: Click here to enter a date.
PATIENT RECEIPT OF REPORT If possible, please ask the patient to sign below to indicate they have received and read this Report.
NOTE: You have a right to access any documents in the mental health service’s possession that are in connection with the hearing at least 48 hours before the Tribunal hearing. If you would like access to those documents, please discuss this with your treating team.
Signed: Date: Click here to enter a date.
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MHT 36 Secure Extended Care Unit Report Local Patient Identifier
FAMILY NAME
GIVEN NAMES
DATE OF BIRTH SEX Mental Health Statewide UR Number Place patient identification label (if available)
Form last updated: May 2017
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