GP Mental Health Care Plan Step 1 - Patient Assessment

GP MENTAL HEALTH CARE PLAN
Item No: 2715 (Assessment & Plan)
Step 1 - Patient Assessment
Patient Name: <<Patient Demographics:Full Details>> Outcome Tool Result
K10
DOB: <<Patient Gender: <<Patient Date: <<Miscellaneous:

Demographics:DOB>> Demographics:S Date>>
ex>>
Referring GP Name: <<Doctor:Name>>

Details:
Practice: <<Practice:Name>>
Provider <<Doctor:Provider Number>>

No:
- the GP must document a mental disorder in the Plan
Problem/Diagnosi
s
Number 1: <<Principal problem/diagnosis 1>>
Medications
<<Clinical Details:Medication List>>
Past History
Mental Health History/Treatment

Has the person ever received specialist mental health care? <<Previous specialist mental health care>>
Other Relevant Information:

Language spoken at home: <<Language spoken at home>>
How well does the person speak English: <<How well is English spoken>>
Family History
<<Clinical Details:Family History>>
Social History
<<Clinical Details:Social History>>
Does the person live alone: <<Does the patient live alone>>
Highest education level completed: <<Highest education level completed>>
Other Relevant Information:

Alcohol: <<Clinical Details:Alcohol>>
Smoking: <<Clinical Details:Smoking>>

<<Clinical Details:Smoking Quitting Stage>>
Page 1
Allergies
Personal History/Lifestyle Issues (eg childhood, substance abuse, relationship history, coping with
previous stressors)
Relevant Physical and Mental Examination
Investigations
<<Summary:Investigation Results (Selected)>>
Mental Status Examination

Appearance and General Behaviour Mood (Depressed/Labile)
q Normal q Other: q Normal q Other:
Thinking (Content/Rate/Disturbances) Affect (Flat/blunted)
q Normal q
Other: q Normal q Other:
Perception (Hallucinations etc.) Sleep (Initial Insomnia/Early Morning Wakening)
q Normal q
Cognition (Level of Consciousness/Delirium/Intelligence) Appetite (Disturbed Eating Patterns)
q Normal q
Attention/Concentration Motivation/Energy
Memory (Short and Long Term) Judgement (Ability to make rational decisions)

Insight Anxiety Symptoms (Physical & Emotional)
q Normal q
Orientation (Time/Place/Person) Speech (Volume/Rate/Content)

Risk Assessment
Suicidal Ideation Suicidal Intent
Current Plan Risk to Others
Key Family/Support Contact <<Key family/support contact & phone No>>
FORMULATION
Main Problems/Diagnosis
(Risk/protective factors)
Other Mental Health Professionals Involved in Patient Care

Name/Profession: Contact Number
Patient Education Given?

Mental Health Link (24 hour support service) 1800 011 511
Suicide Call Back Service 1300 659 467
www.suicidecallbackservice.org.au
GP Psych Support 1800 200 588
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Page 3
Step 2 - Mental Health Care Plan
Patient Name: <<Patient Demographics:Full Details>>
Problem/Diagnosis Goal (eg reduce symptoms, Action/Task (eg psychological or pharmacological

improve functioning) treatment, referral, engagement of family and other supports)
Number 1:
<<Principal problem/diagnosis 1>>
Number 2:
Number 3:
Emergency Care/Relapse
Prevention
Patient Education given: Yes No Key family contact/support details/phone:
Copy of MH Plan given to patient: Yes No
Initial Action Plan - to be considered for: Taking into account the issues that you and the patient have identified, summarise the
initial action suggested (Highlight appropriate tick box and type an "x")
q Diagnostic assessment q Psycho-education q Interpersonal Therapy

q Cognitive Behavioural Therapy (CBT)
q Behavioural interventions q Relaxation strategies
q Cognitive interventions (specify) q Skills training
q Other CBT interventions (specify) :
q Other (specify):
Joint Session Request (OPTIONAL): Tick either first or last session AND either GP Practice or Res.Aged Care Fac.
First q OR qLast session AT qGP Practice OR qResidential Aged Care Facility

Review Date:
(Add a Recall in MD for
1-6 months after the
Plan date)
Record of Patient Consent
I, , (patient name - please print clearly)

Consent to this Care Plan to proceed and I agree to information about my mental health being recorded in my medical file
and being shared between the GP and the counsellor(s) to whom I am referred, to assist in the management of my health
care.
Signature (patient): Date:
I (GP) have discussed the proposed referral(s) with the patient and am satisfied that the patient understands the proposed
uses and disclosures and has provided their informed consent to these.
GP Signature GP Name Date
Referring GP Name: <<Doctor:Name>>
Page 4
Details: Practice: <<Practice:Name>>
Provider No: <<Doctor:Provider Number>>
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GP Mental Health Care Plan Step 1 - Patient Assessment

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GP Mental Health Care Plan Step 1 - Patient Assessment

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GP MENTAL HEALTH CARE PLAN

Item No: 2715 (Assessment & Plan)

Step 1 - Patient Assessment

Patient Name: <<Patient Demographics:Full Details>> Outcome Tool Result

DOB: <<Patient Gender: <<Patient Date: <<Miscellaneous:

Referring GP Name: <<Doctor:Name>>

Provider <<Doctor:Provider Number>>

- the GP must document a mental disorder in the Plan

Mental Health History/Treatment

Other Relevant Information:

Highest education level completed: <<Highest education level completed>>

Other Relevant Information:

Smoking: <<Clinical Details:Smoking>>

Relevant Physical and Mental Examination

Mental Status Examination

q Normal q Other: q Normal q Other:

q Normal q Other: q Normal q Other:

Other Mental Health Professionals Involved in Patient Care

Patient Education Given?

Problem/Diagnosis Goal (eg reduce symptoms, Action/Task (eg psychological or pharmacological

q Diagnostic assessment q Psycho-education q Interpersonal Therapy

q Cognitive interventions (specify) q Skills training

q Other CBT interventions (specify) :

First q OR qLast session AT qGP Practice OR qResidential Aged Care Facility

Record of Patient Consent

I, , (patient name - please print clearly)

Signature (patient): Date:

GP Signature GP Name Date

Referring GP Name: <<Doctor:Name>>

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