Mental Health Commander Recommendation
Note, the role of the MH Commander is to assist ED with MH presentations to reduce wait times and improve flow to the ACT service. Please note, this review is not a comprehensive mental health assessment.
Situation:
Patient presented to the Emergency Department with acute suicidal ideation.
Presenting Problem:
- Patient reports feeling overwhelmed and hopeless due to recent job loss and relationship difficulties.
Background:
Past Psychiatric History:
- Patient has a history of major depressive disorder, diagnosed 3 years ago. Previously treated with sertraline.
Medical History:
- Patient reports no significant medical history.
Medications:
- Patient is not currently taking any medications.
Substance Use:
- Patient reports occasional alcohol use, but denies any current substance use.
Mental Status Examination:
- Appearance: Patient appears dishevelled and tearful.
- Behavior: Patient is restless and agitated.
- Speech: Speech is pressured and rapid.
- Mood: Patient reports feeling sad and hopeless.
- Affect: Affect is constricted.
- Thought Process: Thought process is racing and tangential.
- Thought Content: Patient reports suicidal ideation with a plan.
- Perception: No perceptual disturbances noted.
- Cognition: Cognition appears intact.
- Insight: Patient acknowledges the need for help.
- Judgment: Judgment is impaired due to suicidal ideation.
Risk Assessment:
- High risk of suicide due to active suicidal ideation with a plan.
Recommendation:
- Immediate referral to the Crisis Assessment Team (CAT) for further assessment and possible admission.
- Patient to remain under constant observation until CAT assessment is complete.
- Safety plan to be developed with the patient.
Note, the role of the MH Commander is to assist ED with MH presentations to reduce wait times and improve flow to the ACT service. Please note, this review is not a comprehensive mental health assessment.
Situation:
Presenting Problem:
- [describe presenting problem] (only include presenting problem if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Background:
Past Psychiatric History:
- [describe past psychiatric history] (only include past psychiatric history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Medical History:
- [describe medical history] (only include medical history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Medications:
- [mention current medications] (only include current medications if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Substance Use:
- [describe substance use] (only include substance use if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Mental Status Examination:
- Appearance: [describe appearance] (only include appearance if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Behavior: [describe behavior] (only include behavior if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Speech: [describe speech] (only include speech if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Mood: [describe mood] (only include mood if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Affect: [describe affect] (only include affect if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Thought Process: [describe thought process] (only include thought process if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Thought Content: [describe thought content] (only include thought content if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Perception: [describe perception] (only include perception if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Cognition: [describe cognition] (only include cognition if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Insight: [describe insight] (only include insight if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Judgment: [describe judgment] (only include judgment if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Risk Assessment:
- [describe risk assessment] (only include risk assessment if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Recommendation:
- [mention follow-up plan] (only include follow-up plan if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points with "-", depending on the format, as needed to capture all the relevant information from the transcript.)