PATIENT ASSESSMENT

GPMHSC

Written By Jackson Oppy (Super Administrator)

Updated at July 27th, 2024

Patient wellbeing assessment and recovery plan – Adults

Notes: This form is designed for use with the following Medicare Benefits Schedule (MBS) items. Users should be familiar with the most recent item definitions and requirements.

MBS item number: 2700 2701 2715 2717

This document is not a referral letter. A referral letter must be sent to any additional providers involved in this Mental Health Treatment Plan.

Major headings are bold; prompts to consider lower case. Response fields can be expanded as required. Underlined items of either type are mandatory for compliance with Medicare requirements.

Contact and demographic details

GP name

GP phone

GP practice name

GP fax

GP address

Provider number

Relationship

This person has been my patient since

and/or

This person has been a patient at this practice since

Patient surname

Date of birth (dd/mm/yy)

Patient first name/s

Preferred name

Gender

Female Male Self-identified gender:

Patient address

Patient phone

Preferred number:

Can leave message? Yes No

Alternative number:

Can leave message? Yes No

Medicare No.

Healthcare Card/Pension No.

Highest level of education completed

Primary school

Secondary school

TAFE

Tertiary degree

Comments:

Is this person a parent of a child aged <18 years? Yes No

Carer/support person contact details

Has patient consented for this healthcare team to contact carer/support persons?

First contact:

Relationship:

Phone number 1:

Phone number 2:

Yes

With the following restrictions:

Second contact:

Relationship:

Phone number 1:

Phone number 2:

Yes

With the following restrictions:

Emergency contact person details

Has patient consented for this healthcare team to contact emergency contacts?

First contact:

Relationship:

Phone number 1:

Phone number 2:

Yes

Second contact:

Relationship:

Phone number 1:

Phone number 2:

Yes

Salient communication and cultural factors

Language spoken at home

English

Other:

Interpreter required

Yes, Comments:

Country of birth

Australia

Other:

Other communication factors

Other relevant cultural factors

Patient wellbeing and assessment

Reasons for presenting

Consider asking:

What are the patient’s current mental health issues?
What requests and hopes does the patient have?

History of current episode

Consider:

Symptom onset, duration, intensity, time course

Patient history

Consider:

Mental health history

Salient social history

Salient medical/biological history

Consider asking:

♀ – menarche, menstruation, pregnancy, menopause

Salient developmental issues

Family history of mental illness

Consider asking about:

Family history of suicidal behaviour
Genogram

Parent and children needs

Record:

Name and date of birth of any children aged ˂18 years.
Impact of mental health difficulties on their parenting, the parent–child relationship and their children

Current domestic and social circumstances

Consider asking about:

Living arrangements
Social relationships
Occupation

Salient substance use issues

Consider asking about:

Nicotine use
Alcohol use
Illicit substances
Is patient willing to address the issues?

Current medications

Consider asking about:

Dosage, date of commencement, date of change in dosage
Reason for the prescription
Are there other practitioners involved in the prescription of medication?
Are there issues with compliance or misuse

History of medication and other treatments for mental illness

Consider asking about:

Past referrals
Effectiveness of previous treatments
Side effects and complications associated with previous treatments
Patient’s preference for medications

Allergies

Relevant physical examination and other investigations

Results of relevant previous psychological and developmental testing

Other care plan

e.g. GP Management Plans and Team Care Arrangements;

Wellness Recovery Action Plan; Family Care Plan

Yes, Specify:

Comments on Strengths and Positive Dispositions

Consider asking about:

Abilities, talents and interests
Competencies and accomplishments
Previous self-help strategies used and those available in the family support network
Service system and the community at large

Comments on Current Mental State Examination

Consider asking about:

Appearance, cognition, thought process, thought content, attention, memory, insight, behaviour, speech, mood and affect, perception, judgement, orientation
Appropriateness of Mini-Mental State Examination (MMSE) for patients aged ˃75 years or if otherwise indicated

Trauma Informed Care and Practice (TICP) assessment.

Consider possible influence of trauma

Trauma can be defined as:

Exposure to death
Threatened death
Actual serious injury
Threatened serious injury
Actual sexual violence
Threatened sexual violence

Consider possible indicators of gender-based violence-related trauma

Possible indicators may include:

Stress, anxiety, depression
Substance use disorders
Thoughts, plans or acts of self-harm/suicide
Injuries that are repeated and unexplained
Repeated sexually transmitted infections
Unwanted pregnancies
Unexplained chronic pain or conditions (pelvic pain, gastrointestinal problems, kidney or bladder infections)
Other unexplained mental health complaints

Risk assessment

If high level of risk indicated, document actions taken in the treatment plan below

Consider asking:

Does the patient have a timeline for acting on a plan?
How bad is the pain/distress experienced?
Is it interminable, inescapable, intolerable

Ideation/ thoughts

Intent

Plan

Suicide

Self-harm

Harm to others

Comments or details of any identified risks

Assessment/outcome tool used

(except where clinically inappropriate)

Date of assessment

Results

Copy of completed tool provided to referred practitioner

Provisional diagnosis of mental health disorder

Consider conditions specified in the International classification of primary care, 2nd edition:

Depression
Bipolar disorder
Other mood disorders
Anxiety disorders
Panic disorder
Phobic disorders
Post-traumatic stress disorder
Schizophrenia
Other psychotic disorders
Adjustment disorder
Dissociative disorders
Eating disorders
Impulse-control disorders
Sexual disorders
Sleep disorders
Somatoform disorders
Substance-related disorders
Personality disorders
Unknown

Case formulation

Consider asking about:

Predisposing factors
Precipitating factors
Perpetuating factors
Protective factors

Other relevant information from carer/informants

Consider asking about:

Specific concerns of carer/family
Impact on carer/family
Contextual information from members of patient’s community
Content from individuals other than the patient

Any other comments

Record of patient consent for personal recovery plan

I, ___________________________________________________ [name of patient], agree to complete the recovery plan.

Considering the recovery journey – Optional frameworks, stages and tasks to consider

Stage of personal recovery
1. Feeling overwhelmed	2. Acknowledging change is needed	3. Actively struggling with mental health	4. Living with impact of illness or vulnerability	5. Living beyond illness or vulnerability
Notes informed by stages 1–5 above; consider small, comprehensible and achievable steps

Recovery task 1 – Understanding my mental health, and what it means for me
Has confusion about what happened and what it means	Is aware that something needs to be understood or sorted out	Has a beginning explanatory model of causal attributions	Has come to terms with mental health and what it means to them	Is comfortable with own personal understanding of experiences
Notes informed by dimensions of task 1: consider small, comprehensible and achievable steps

Recovery task 2 – Taking charge of my mental health
Is not making a deliberate effort to cope	Realises the need to cope or change	Is sometimes trying ways to cope or change	Is generally confident in managing persisting illness or vulnerability	Mental health experiences interfere little with life
Notes informed by dimensions of task 2: consider small, comprehensible and achievable steps

Recovery task 3 – Living a life that I value
Feels disconnected from people, social roles and personal growth	Would like to be more connected to people, social roles and personal growth	Is sometimes trying ways to connect and change	Has found a place in life but still limited by disabilities	Has a ‘contributing life’
Notes informed by dimensions of task 3: consider small, comprehensible and achievable steps

Setting personal recovery goals

Also consider:

The person themselves prioritising the goal/s to focus on
The CHIME framework: connectedness, hope, identity, meaning and purpose, and empowerment
Which strengths are relevant and can be built on to pursue goal/s
How the person’s values, treatment and support preferences will impact on the action plan
Breaking goals down into smaller manageable steps and making plans for who will do what and when – informally or using the SMART (specific, meaningful, attainable, realistic, timetabled) approach
Supporting the person to undertake independent or joint actions rather than accepting passive actions

Personal recovery plan
		Actions
Identified issues/problems Consider: As presented by patient Developed during consultation Formulated by GP	Goals Consider: Goals made in collaboration with patient What does the patient want to see as an outcome from this plan? Wellbeing, function, occupation, relationships Any reference to special outcome measures Time frame	Treatments & interventions Consider: Suggested psychological interventions Medications Key actions to be taken by patient Support services to achieve patient goals Role of GP Psycho-education Time frame Internet-based options	Referrals Consider: Practitioner, service or agency – referred to whom, and for what Specific referral request Opinion, planning, treatment Case conferences Time frame Referral to internet mental health programs for education:	Any role of carer/support person/s Identified role or task/s (eg monitoring, intervention, support) Discussed, agreed, and negotiated with carer? Any necessary supports for carer Time frame
Issue 1:
Issue 2:
Issue 3:
Intervention/relapse prevention plan(if appropriate at this stage) Consider asking about: Warning signs from past experiences Arrangements to intervene in case of relapse or crisis Support services currently in place Any past effective strategies		Preparation of plan for delegation of patient’s responsibilities (e.g. care for dependants, pets)
Psycho-education provided if not already addressed in “treatments and interventions” above?			Yes No
Plan added to the patient’s records?			Yes No

Other healthcare providers and service providers involved in patient’s care (e.g. psychologist, psychiatrist, social worker, occupational therapist, other GPs, other medical specialists, case worker, community mental health services)
Role	Name	Address	Phone

Completing the plan

On completion of the plan, the GP may record (tick boxes below) that they have:

Discussed the assessment with the patient

Discussed all aspects of the plan and the agreed date for review

Offered a copy of the plan to the patient and/or their carer (if agreed by patient)

Date plan completed

Record of patient consent
I, ___________________________________________________ [name of patient], agree to information about my health being recorded in my medical file and being shared between the GP and other healthcare providers involved in my care, as nominated above, to assist in the management of my healthcare. I understand that I must inform my GP if I wish to change the nominated people involved in my care. I understand that as part of my care under this Mental Health Treatment Plan, I should attend the general practice for a review appointment at least four weeks, but no later than six months, after the plan has been developed. I consent to the release of the following information to the following carer/support and emergency contact persons.
Name	Assessment				Treatment Plan
	Yes			No	Yes	No
	With the following limitations:				With the following limitations:
	With the following limitations:				With the following limitations:
__________________________________________ Signature of patient			________/________/________ Date
I, ________________________________________, have discussed the plan and referral/s with the patient. Full name of GP
Mental Health Treatment Plan Included: __________________________________________ Signature of GP		No Yes (if yes, please select below) MBS item number: 2700 2701 2715 2717 ________/________/________ Date

Request for services

	Date: To: [Attn] [Address] [Post code] Subject: Letter of request for services Dear Dr I am referring [patient’s name] for I am referring [patient’s name] [date of birth] for [number of sessions] sessions. I have been [patient’s name]’s primary care physician for the past [number of years] years. In summary, the following assessment and treatment planning has been undertaken: [ ] Mental Health Treatment Plan attached: Yes No Specific treatment requests: [ ] If you have any questions, please feel free to contact me directly. I will be available on phone [T+00000000] and email [email@email.com] in case of any query. Looking forward to your reply. Yours sincerely, [Signature] [Physician’s name and title] [Provider number]
REVIEW
MBS item number: 2712 2719
Planned date for review with GP (Initial review four weeks to six months after completion of plan)
Actual date of review with GP
Assessment/outcome tool results on review (except where clinically inappropriate)
Comments Consider: Progress on goals and actions Identified actions have been initiated and followed through (e.g. referrals, appointments, attendance) Checking, reinforcing and expanding education Communication between the GP and patient Where appropriate, communication received from referred practitioners Modification of treatment plan if required
Intervention/relapse prevention plan (if appropriate) Consider: Warning signs from past experiences Arrangements to intervene in case of relapse or crisis Other support services currently in place Any past effective strategies

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