Documentation & the MSE

1 CNE point

Good documentation – good defencePoor documentation – poor defenceNo documentation – no defence

Objectives - Documentation

Participants will:• have a greater appreciation / understanding

of the need of accurate documentation in the mental health setting

• be able to demonstrate use of the documentation framework presented

• have a great awareness of professional accountability and documentation

Objectives - MSE

• to visit/revisit the essential components of an MSE• to consolidate current knowledge of conducting and interpreting an MSE• to practice conducting and writing up an MSE

Increased awareness and curiosity• about the language used • messages, interpretations and meanings provoked and transferred in the documentation

Problem based and solution focused

Documentation

Reflects the professionalism, competence, respect for patients and their families and the degree of competence with the policies and procedures of the workplace (Navuluri, 2001)

The quality of documentation can determine whether a malpractice attorney accepts or declines a suicide case(Simpson & Stacy, 2004)

Benefits to the client

• Ensures the client is consulted and included in their care planning and that their decisions are recorded• Supports continuity of care – allows professionals involved in care to safely take over the clients ongoing care • Gives useful historical information for future care• Provide a legal document of the care they received (QNC, 2005)

Benefits to the health professional

• Gives clear and dependable instructions• Highlights unique contribution to care• Increases professional credibility by recording clinical judgement, delegation decisions and critical thinking• Involves a structured reflective reasoning process (identifying an emerging pattern)• Saves time – less energy spent searching for information/instructions • Provides reliable, accurate and complete information for safe and effective care & treatment (QNC, 2005)

Benefits to organisation

• Provides complete & reliable data to justify financial expenditure and resource allocation such as staffing levels and equipment• Facilitates research, auditing and quality improvement processes (QNC, 2005)

F.A.C.T.U.A.L.

Focused on the clientAccurateCompleteTimelyUnderstandableAlways objectiveLegible(QNC, 2005)

Patient settled ATOR

Patient more settled today, less intrusive. S/B S.W. today. Spending time in courtyard. Plans to go to local shops today

Patient given 1:1 time. Pt struggling and reports low mood. Pt reactive throughout 1:1. Pt continues to use CBT techniques from last admission and is able to stop irrational thoughts. Encouraged patient to seek support.

Reported increase in suicidal thoughts (no intent) early in the shift but these subsided following prn diazepam. Superficial conversation with staff only

M S E ..is

• Used as a screening tool to assess an individuals current neurological & psychological status• A means to transfer knowledge and clinical practice• A guide to individuals presentation and progress• Involves observations as well as an interview• Assess safety

Important part of treatment planning

MSE

• Appearance & Behaviour• Speech• Mood & Affect• Thought content / processes• Perception• Insight & Judgement • Sensorium & cognition• Safety

Appearance & Behaviour

• Describe the individuals physical appearance (grooming, hygiene, clothing, nails, build, tattoos, piercing)

• Individuals reaction to your interaction/ being admitted / present situation (hostile, friendly, grandiose, withdrawn, uncommunicative, seductive)

• Motor behaviour (psychomotor retardation, restless, repetitive behaviours, hyperactive, tremor, hand wringing bizarre, agitated, anxious)

Speech

Rate (slow, accelerated, normal)

Volume (loud, soft, whispered)

Quantity of information

Mutism (absence of speech)

Poverty of speech (responses brief & monosyllabic)

Pressure of speech (rapid, difficult to interrupt, loud and hard to understanding)

MoodDefined in the Diagnostic and Statistical Manual of Mental

Disorders IV (DSM IV) “is a pervasive and sustained emotion that colours the perception of the world. Variations in mood occur as a normal response to specific life experiences. Those responses are transient and are not associated with significant functional impairment such as depression elation, anger, and, anxiety”.

• With a mood disorder: “the individual has persistent or recurrent disturbances or alterations in mood that continually cause psychological stress and behavioural impairment over the year” (Boyd & Nihart 1998:439).

• Internal feeling or emotion – often influences behaviour

Depressed, labile, euphoric, fearful, hostile, anxious, dysphoric, euthymic

What about……

exhausted, confused, ecstatic, guilty, confidentshy, bored, surprised, overwhelmed, embarrassed, thoughtful, relived, impressed, determined

Affect Reactive (normal)Restricted (decreased intensity & range)Blunted (severe decease in intensity & range of emotional expression)Flat (almost complete or complete absence of emotional expression - usually accompanied with monotonous voice)

What about …..

- the observable expression of emotion

- striated muscles controlling face, posture, vocalization(Nathanson, 1992)

Shame, humiliation

Interest, excitement, enjoyment

Surprised, startled

Fear, terror

Distress, anguish

Anger, rage

Dissmell, disgust

(Nathanson, 1992;Tomkins, 1963)

Thought contentAmount of thought and rate of production

– Poverty of ideas– Flight of ideas– Slow/hesitant thinking– Vague

Continuity of ideas– Logical order– Tangential

Disturbance in language– New words– Conversations that do not make sense

Thought processes

Thought blocking

Circumstantiality

Confabulation

Fragmentation

Loose associations

Tangentiality

Perseveration

Flight of ideasNeologism

Word Salad

Thought Content

Delusions– Fixed beliefs (grandiosity, jealousy, fantastic, nihilistic, religious)

Suicidal thoughts– Transient, intrusive, persistent– Plan

Other – Obsessions, antisocial urges,

hypochondriacal

• Delusions of persecution• Delusional mood• Delusions of reference• Delusions of control, influence or

passivity • Religious delusion• Nihilistic beliefs• Fantastic delusions• Delusions of jealousy• Grandiose delusions

Perception

Hallucinations

auditory

visual

olfactory

gustatory

tactile

somatic

Derealisation

Depersonalisation

Heightened perception

Dulled perception

Insight & Judgement

JudgementDuring the course of an assessment many aspects of the individuals capacity for social judgment may be obvious. The clinician has to make an assessment on whether or not the individual has the ability and capacity to self assess what is happening around them and to make important discussions in their own best interests.

InsightRefers to the DEGREE of awareness and understanding that the person has that she/he is ill. May be total denial. Some awareness but still denying. Awareness of illness but blaming on others. Acknowledge the illness but ascribe it to some unknown illness or event.

Sensorium & cognitionAttention and concentration• Provides an assessment on

whether the person is alert and able to follow the interview or whether they are easily distracted by other things happening around them.

Poor concentration• May be due to inefficiency of

thinking, distractability, anxiety, delusions etc. (Assessment tool named Serial 7’s can be used to assess concentration – ask person to subtract from 100 by 7’s - how far can they go).

Orientation• To time, place and person• True disturbances in

orientation are found only in organic mental disorders.

Memory - loss of: • Immediate (recall and

retention) (give your name, date 10 mins later can the person recall)

• Recent (what did they have for breakfast? what did they do yesterday?)

• Remote (ask questions about persons childhood, important events in their life)

General knowledgeHow is the person at counting, telling the time, naming the prime minister, what is the latest news

Abstract thinkingGenerally assessed by asking the person to interpret proverbs (i.e. a rolling stone gathers no moss). However this can be difficult to assess based on persons intelligence, culture, language, beliefs.The presentation of changes to one or more of those process (attention, concentration, thinking etc) may be caused by a number of factors such as physical complications: (tumour, infection, or pain); influence of drugs (prescribed and non prescribed, or alcohol), post effects of poisoning deliberate or non deliberate:

Safety Suicidal, homicidal, self harm and

impulsive thinking – behaviour are important in the area of MSE

Consider also safety in terms of vulnerability

(sexual activity – consumer/consumer, consumer/staff member, consumer/external other)

Other safety considerations include: AWOL physical risks, child safety

MSE (or CP)

A Attending to ADL’s. Casual attire Socialising with peers, engaging with staff, good eye contact, participating in groups today (self esteem)

S Normal rate and flowM describes mood as “low”, rates on scale of 1-10 as 3 states that her mood “gets better as day progresses” and last night scored her mood as 6 Reactive affect in conversationT States that she has been “experiencing thoughts of self harm especially in the

mornings”. States does not want to “self harm whilst in hospital” “want to try the new strategies that I have been learning”

No obvious thought disturbances voiced or observed during interactionP No obvious perceptual disturbance observed or voiced during interactionI During interaction patient demonstrated insight about her admission and about

her self harm thoughts. Pt. has the capacity to self assess as demonstrated in behaviour not to follow through with self harm thoughts

S Patient alert, short and long term memory intact, able to engage in a conversation for 30 mins

S Patient has stated that she has felt safe this morning and has not experienced any suicidal or self harm thoughts to time of report

Presenting a picture of the patients presentation to the reader

Interventions Tell the reader what you did

• Staff time – 30 mins• Discussed with patient the issues they were concerned about (family, work)• Encouraged patient to identify strategies to manage concerns (journaling, discuss concerns with partner) • Developed with patient hierarchy of self harm reduction strategies (same attached to front of chart)• Accompanied patient on walk round hospital grounds - observed interest patient expressed in physical surroundings• Patient offered PRN medication

Outcomes

• Patient’s safety maintained throughout shift• Patient’s level of distress increased following discussion

and patient has verbally stated that they are not suicidal and will approach staff if they are feeling unsafe and wish staff time and or prn medication,

• Patient maintained on 30/60 visual obs • Dr Blogg’s informed re patients progress/status

Inform the reader about the effectiveness of the interventions that you used

In summary

• Be guided by policies of organisation• Be aware of the value of your

documentation• Be thoughtful of what you write and how

you write it• Be aware that patients can access their

notes – include them in your readership• Initially takes time to use the framework –

easier with practice

Preparing for discharge …

What is the individuals wishes ……?

References• Elder, R., Evans, D, & Nizette, D. (2004). Psychiatric and Mental Health

Nursing. Elsevier Australia: Marrickville.• Navuluri, R. (2001). Documentation: What, why, where, who and how?

Research for Nursing Practice, 3(1). Retrieved 10 August 2006 from http://www.ateresearch.com/Navu-Docu.htm

• Nathanson, D.L. (1992). Shame and pride. Affect, sex, and the birth of the self. New York: W.W. Norton & Company.

• Queensland Nursing Council. (2005). Professional documentation standards. Framework Information Sheet No 3.

• Simpson, S., & Stacy, M. (2004). Avoiding the malpractice snare: Documenting suicide risk assessment. Journal of Psychiatric Practice, 10, 185-189.

• Tomkins, S. (1963). Affect, imagery, consciousness. Vol 2. The negative affects. New York: Springer.

• Sanders, M. R., Mitchell, C., & Byrne, G. J. A. (Eds.) Medical Consultation Skills. Behavioural and Interpersonal Dimensions of Health Care. Addison-Wesley: South Melbourne.