NSW Mental Health Clinical Documentation


Appropriate clinical documentation forms a basis for mental health care in New South Wales (NSW), Australia. It is essential to carry out a subjective assessment and diagnosis on a patient and this is made possible by the Mental Health Outcomes and Assessment Tools (MH-OAT). Unfortunately, reviews of critical incidents in NSW health have indicated several shortcomings in clinical documentation. As a result, standardized modules for assessing the mental health of consumers have been established so as to ensure favourable documentation during all stages of care. This paper aims at analyzing efficiency during these stages with a special focus on the base modules, risk assessment and physical examination as MH-OAT.

Base Modules

The base modules include: “Triage, Assessment, Care Plan, Review and Transfer/Discharge Summary” (NSW Department of Health 2004, 3-5). The base modules are the initial step in mental health clinical documentation and apply in all settings and to all age groups. The base modules are useful to both the consumers and clinicians in that the consumers can be done a more thorough type of clinical documentation. The clinicians on the other hand are able to obtain information from different domains hence, are able to make the correct and relevant type of intervention with regard to the clinical documentation.

The Triage as a type of a base module is very imperative in determining the urgency of a situation. It is important to the clinician in that it enables him or her to evaluate the seriousness of a situation hence, make appropriate intervention plans. The use of the triage has been associated with quality nursing care (Department of Health 2008, 6-8). In the context of MH-OAT, triage is meant to associate a consumer with the correct mental health care service providers.

The triage module is susceptible to biasness especially when conducted over the phone. Despite the fact that telephone triage may seem reliable and convenient for patients, the clinician is likely to document false information. In addition, the telephone triage is not credible with regard to the consumer giving out the information. If the consumer is mentally unfit, then the quality and significance of information given out is questionable (Adams, et al 2000, 194-196).

The triage makes use of the Crisis Triage Rating Scale that has a maximum total score of fifteen. The score is measured based on three factors, namely: if the consumer is a menace to themselves or other people, their capacity to cooperate and their support system. To ensure compliance and consistent use of the scale, adequate training of staff is imperative so that they are able to handle the challenges associated with the MH-OAT (Cleary 2004, 57-59).

There should be different kinds of assessment basic modules depending on the consumers. There are consumers who have less severe forms of mental illnesses and there are those with severe forms of mental illnesses. As a result some information the mental clinical documentation form is not relevant to certain consumers thus; blank spaces will be left out in some instances. To avoid wastage of space and time, it would be necessary to come up with refined forms for different kinds of consumers (Cleary et al 2005, 74-77).

The assessment base module enables the clinician to obtain adequate information that forms a basis for comprehensive health care plan intervention. The care plan module is evaluated through use of the health nation outcome scales (HoNOS) (Kisely 2008, 248-250). It enables the clinicians to make a follow up of the intervention given to patients.

Risk Assessment

The risk assessment module should be used to document information in a structured format contrary to the idea that it should be used to conduct the assessment. During risk assessment, it is important to include the strengths and difficulties questionnaire (SDQ) as a MH-OAT tool that fosters and enhances participation of the consumer. This is a very critical phase for a consumer with mental instability as it is associated with adverse effects if not carried out effectively (Lyons et al 1997).

The risk assessment module is important to assess different levels of risk within an individual. It enables clinicians to determine consumers’ suicide and violent risks so as to come up with the correct mode of risk management. A suicide risk assessment tool guide is essential as it enables the clinician to assess an individual’s level of suicide risk. However, the risk assessment tool guide should only be perceived as a guide and not a clinical decision making tool. The clinician’s knowledge and judgment is important when it comes to estimating an individual’s suicide risk (Callaly, Arya and Minas 2005, 17-19).

The risk assessment module acts as a basis for provision of evidence based nursing care. This is because, through good clinical documentation, clinicians are able to make follow ups and evaluate the different types of nursing care given to the consumer. This subsequently allows for a more appropriate and effective type of intervention. The risk assessment MH-OAT should be appropriately documented for use by any clinician. The risk assessment module should be used to foster team work in provision of health care services. Clinicians need to consult one another with regard to when a SDQ should be administered. In addition, the SDQ should be administered in accordance with the MH-OAT protocols (Brooks 2000, 507-510).

Risk assessment module requires frequent attention due to changes within an individual as a result risk exposure. The mental health documentation form should be modified based on the priority of the consumers’ health. Risk assessment as a very crucial phase requires a lot of attention but with the comprehensive metal health documentation form, attention is shifted to diverse facets (Lyons et al 1997).

The SDQ questionnaire used for risk assessment is very comprehensive for a patient who is not fit. Recording information in this questionnaire would be more objective if the consumer were accompanied by a relative or a home care giver. This should be factored in because a person who is not mentally fit is susceptible to fluctuations in mood and due to the complexity of the questionnaire, poor documentation would result (Fernstein, 1967).

Physical Examination

The physical examination module is conducted in concordance with the mental health standards and guidelines. It is a critical factor during admission of inpatients. However, there should be clear guidelines pertaining to the physical examination module. This is because of the differences involved in conducting physical examination for different consumers (Commonwealth Department of Health and Ageing 2002).

Ethical principles are an important factor that should be considered during physical examination. Privacy, beneficence, autonomy and justice should be looked at during physical examination. Consumers’ information should be handled with a lot of privacy as it is meant for clinical purpose only. Lack of cooperation from a consumer sometimes result in lack of documentation, for instance when a consumer refuses to get a physical examination. The physical examination module should include an engagement process that enlightens the consumer on the essence of the examination (Holloway 2002, 1-2).

Physical examination should be done as a process aimed at benefiting the patient and not as a usual routine. The perception that physical examination is just another usual routine may result in clinicians failing to accord seriousness to the process as required. The complexity of the physical examination module given the instability and numbers of consumers may cause some neglect in some facets of the physical examination module. A lot of time is required for a nurse to physically examine his or her patient. Unfortunately, due to the volume of workload experienced by the nurses, effective and efficient documentation of the mental health form is not achieved (Patterson 2006, 134-135).

It is difficult to comply with the physical examination module in a mental health care because of the differences in the kind of attention needed. A mental health service is aimed at improving a consumer’s psychological condition. Here comes a requirement of physical examination which at the point is not a critical factor. As a result the module has been considered to be cumbersome and time consuming (Preston 2000, 515-517).

All in all, physical examination is an important clinical procedure. It is considered as a support module that enables a clinician to detect additional problems being faced by the consumer. A consumer may regard physical examination as unnecessary due to the fact that as a person seeking mental health services, physical examination is not called for. However, physical examination is important to the consumer because if successfully carried out, a consumer obtains information about his or her health status (Andrew, Peter and Teeson 1994).

The physical examination forms are mere documents which can easily get destroyed. Therefore, it is important to have a more sophisticated means of recording information. For example, hospitals should use health information systems that are based on technology hence, spare clinicians from losing information. In addition, the use of computer health systems is a more sure way of storing consumers’ information (Brooks 2000, 509-510).


The use of clinical health documentation improves the quality if health care delivery but, proper administration of the MH-OAT during the assessment is very important. The current mental health clinical documentation forms have been modified to include 7 modules as opposed to the prior 25 modules. However, it would be much better if the current form were further modified to suit the needs of the different consumers. Appropriate means of obtaining objective information from a consumer who has lost his or her rationale should be included in the modules. This is important so that proper documentation can take place and especially when various clinicians are involved so as to enable follow up of the consumer.


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