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Conducting a comprehensive assessment is critical to ensuring that the person undergoing an assessment and/or their carer’s needs are identified to inform decision making about the evidence based care and treatment required. The assessment will examine the person’s mental health, physical health, social needs and risks that could impact on the safety of the person or those around them. In addition, assessing the needs of any carer is important and will be an important aspect of the assessment process.

As part of the assessment the allocated worker will administer outcome assessment tools which, depending on the tool, are proven to establish the severity of a mental health disorder or other specific needs to help inform effective and safe treatment and care.

The information that is gathered as part of the assessment can be personal and sometimes seem intrusive. The allocated worker conducting the assessment will be sensitive when asking for personal information, however assembling this information is very important to ensure that the right treatment and care is commenced to meet the needs of the patient.

Sometimes assessments have to be repeated by other services that need to be involved in providing care and treatment. Clinical staff will always try to reduce the duplication of assessments; however these may have to be repeated to ensure the effectiveness of the care and treatment provided and in managing risks that could impact on the safety of the person and those around them.

The overall aims of the assessment process are:

  • To ensure that the care and treatment provided addresses the needs that matter the most to the person undergoing the assessment and those significant to them in order to support recovery.
  • To ensure that accurate information is obtained to inform decision making about care and treatment.
  • To ensure that risk to self and others is identified and managed safely and effectively.

Phases of Assessment

To be certain that the overall aims of the assessment process are met the following assessment framework will be used by clinical staff:

1. Reason for referral

  • What is the person undergoing the assessment’s view of the problem?
  • Does anybody else have a view on the person being assessed in terms of their needs?
  • Do the needs of the caregiver require more consideration?
  • What are the presenting problems to include current symptoms and behavior?
  • What is the impact of the presenting problem on the person and those significant to them in terms of safety and wellbeing?
  • Is anybody else involved in their care and treatment and what do they provide?

2. The person’s psychiatric, physical and social history?

  • Any known diagnosis – physical and mental health
  • Past psychiatric history
  • Past family psychiatric history
  • Personal and social history
  • Forensic or criminal justice history

3. Physical health and wellbeing?

  • Current physical health
  • What medication is the person taking for their physical and mental health? Are they concordant with these therapies?
  • Current and previous drugs and alcohol use?
  • What is the current lifestyle of the person being assessed?
  • How is the person and/or carer coping or managing their activities of daily living?
  • If assessing the person at home what does their environment tell you?
  • For people with dementia, is a life story available?
  • Are there any recent physical health investigations available?

4. Current Mental State

As well as focusing on the person being assessed, history questions and observations will examine the current presentation in relation to:

  • Appearance and behaviour
  • Speech, eye contact, psychomotor activity
  • Mood
  • Thoughts
  • Perceptions
  • Cognition
  • Non cognitive symptoms of dementia

5. Risk Assessment

A comprehensive risk assessment will be carried out to gather important information to formulate the risks. The formulation will enable to the allocated worker, person being assessed and/or carer to work together to collaboratively manage the risk and inform decision making about any urgent interventions.

Risk assessment will examine the risk to self and/or others, and if there is a risk of exploitation and/or neglect.

Additional assessment considerations for service users with possible personality disorder

6. Next steps

  • What does the service user/carer want and need from the service?
  • What matters the most to the service user and carer?
  • Where do the service user and/or carer want to be in three months’ time?
  • Do they have any current solutions to their concern?
  • How will they know things are getting better?
  • What does the relevant outcome assessment tool(s) indicate at this stage?
  • Are any physical health investigations required?
  • Is there anybody who needs to be spoken to?
  • What needs to happen today, in 72 hours and a week to include any urgent referrals required to meet the needs of the service user and those significant to them?

Once the assessment is completed decision making about interventions will be guided the relevant disorder pathways by selecting the diagnosis in the search engine (see About Care Pathway).