O'Brien L, Fitzgerald M, Barber H, Henry J
University of Western Sydney, Nepean and Wentworth Area Health Service, Australia.
Int J Psychiatr Nurs Res. 1999 May;5(1):516-25.
Within public mental health services in Australia, community mental health nurses are often the first point of contact for people presenting with mental health problems. Community mental health nurses are responsible for determining appropriate triage and assessing need for treatment. Community mental health staff identified a need to improve skills in assessment and documentation of psychiatric symptoms. This collaborative study sought to develop an educational package, based on Present State Examination-9, for initial assessment, and a reliable file audit tool to evaluate the effectiveness of the education. Twenty initial mental health assessments completed by twenty different community mental health nurses were audited approximately one month prior to, and two months after, attendance at the education programme. The audit indicated that the documentation of assessments improved in all aspects, although the most significant differences were achieved in recording history, mental state and treatment plan. These items were the main items emphasised in the education programme. It is suggested that the Present State Examination-9 provides a useful base for teaching clinicians how to incorporate the documentation of comprehensive and precise information into assessment formats and treatment planning and that the file audit tool, when linked with an assessment format provides a useful way of evaluating self and peer assessment documentation.
在澳大利亚的公共心理健康服务体系中,社区心理健康护士常常是有心理健康问题者的首个接触点。社区心理健康护士负责确定适当的分诊并评估治疗需求。社区心理健康工作人员发现有必要提高评估和记录精神症状的技能。这项合作研究旨在开发一套基于《现况检查-9》的教育包用于初始评估,并开发一个可靠的档案审核工具来评估教育效果。由20名不同的社区心理健康护士完成的20份初始心理健康评估在参加教育项目前约一个月以及参加后两个月接受审核。审核表明评估记录在各个方面都有所改善,尽管在记录病史、精神状态和治疗计划方面取得的差异最为显著。这些项目是教育项目中重点强调的主要项目。建议《现况检查-9》为教导临床医生如何将全面准确信息的记录纳入评估格式和治疗计划提供了有用的基础,并且档案审核工具与评估格式相结合时,提供了一种评估自我和同行评估记录的有用方法。