Assessment of new inpatients by psychiatrists

The psychiatrist’s first assessment of a new inpatient is of critical importance. A current mental status examination, diagnostic formulation and risk review all contribute to an informed, well-directed and collaborative treatment plan. Oversight by a consultant at the time of admission or shortly afterwards helps all members of the multi-disciplinary team to identify consumers’ needs and respond to them quickly and effectively. An admission process that starts well will deliver a better outcome in a shorter period of time.

The purpose of this Clinical Practice Advisory Note is to articulate the goals of the initial assessment and address a number of practical considerations including the roles of family members, carers, junior doctors and other team members.

The note aims to set a standard of practice that can be checked as part of services’ ongoing quality and safety audits. It was compiled with the assistance of clinicians with medical and nursing expertise.

Assessment goals

The first assessment of a consumer after admission to a mental health inpatient unit (or while waiting in the emergency department for a bed to become available) is critical. It is the starting point of a complex, multi-disciplinary process that aims to engage consumers in safe, effective care with the least possible restriction of liberty. The scope and style of the assessment help set a standard for other team members. Assessments that are conducted by an on-call psychiatrist out of normal working hours are no less important.

The purpose of the initial assessment is to:

• engage actively and positively with the consumer’s concerns and needs
• summarise what is known about the circumstances of the admission and what remains to be established
• seek a collateral history from a family member or carer where appropriate or direct another clinician to seek one
• document the current mental status
• make a provisional diagnosis (or diagnoses) and state what steps are required to clarify the diagnosis
• check for plausible co-morbid conditions including withdrawal from alcohol or other drugs
• record the consumer’s response to the admission and proposed treatment
• give the consumer accurate information about the admission process and likely short-term and medium-term treatments
• work with other clinicians to identify and address the consumer’s immediate concerns about family, home, work and other pressing matters
• prescribe or adjust psychotropic and other medications (if indicated) with adequate ‘as needed’ doses to address short-term distress and behaviours of concern that do not respond to non-pharmacological interventions
• work with the consumer, carers and family members (where appropriate) and other staff members to write a short-term ‘safety plan’ that matches the consumer’s needs (e.g. reassurance, contact with carers, relief from symptoms, prevention of withdrawal from alcohol or other drugs) with the goal of minimising distress and reducing the potential for harm
• identify if leave from the inpatient unit is appropriate
• decide if a Treatment Order is indicated, bearing in mind the need for treatment to be delivered in the least restrictive way possible with the least possible restrictions on human rights and dignity.

Practical considerations

New inpatients should be reviewed by a consultant within 24 hours of admission. The initial assessment must sometimes be conducted briefly and in difficult circumstances. Where elements of the assessment cannot be completed at the time, this should be noted and addressed later.

Documentation must sometimes be very brief but should cover the elements listed above.

Ideally, the consultant should be accompanied by a junior doctor and primary nurse to ensure that conclusions and plans are well communicated to other team members.

It is not necessary to pursue matters that have been established to the consultant’s satisfaction by other clinicians (for example, in the community or emergency department). Current mental and physical status, and issues concerning safety, are subject to change at short notice and must always be re-viewed.

Tasks may be delegated to junior doctors (for example, scribing, requesting tests or contacting carers) provided that directions are stated clearly and performance is supervised.

Where notes are scribed by a junior doctor, they should be reviewed and counter-signed by the consultant.

If family members or carers are present, the consultant should meet them to seek a collateral history (if outstanding) or ask another team member to do so.

Information about the goals of admission and treatment plan should be shared with the consumer, carers or family members if the consumer consents. If the person is involuntary, information can be shared with carers even in absence of consent if the conditions stipulated in section 346 of the Mental Health Act are satisfied.