Ardens have developed this template for you to quickly add detail in a structured way during an initial review. You do not need to complete the whole template, just what is needed at the time. There are useful tick boxes to quickly code to the record and add additional notes. As with all other templates you'll find links to other tools that maybe required whilst using the template, such as mood & memory scores.
This template is embedded within other Ardens templates such as Self-harm and Severe Mental Illness or can be used as a standalone template and can be located in the following ways:
- Auto-Consultation > ardens CONDITIONS MENTAL HEALTH > Mental State Examination
- Use the bottom left search bar in SystmOne
If using the template on a regular basis, save to F12 favourites for quick access.
Home
The Home page shows any outstanding Network Contract DES requirements and a summary of relevant medical history for the patient. This includes diagnosis codes, recent numerics, lifestyle information and any care plans. Further down, any drug monitoring alerts and relevant medication summary.
Bottom left corner of the home section is a link to both the BMJ guidance and ResearchGate websites on conducting a mental state examination.
Appearance & Behaviour
Whilst with a patient this section can be used to record your observations around the patients appearance and current behaviour.
There are presets available along side the Behaviour free text box to quickly add rather than typing, click on the preset button (notepad icon) and add 1 or multiple lines of text by pressing & holding Ctrl on the keyboard and using mouse to select. The text can be edited once added to the template.
Speech
As above each free text box has relevant presets available to quickly add any text.
Mood
Alongside the coding available from each drop down is a link to relevant scored assessment tools - GAD, PHQ & HADS.
Insight & Capacity
If needed there is a link to the Mental Health Act template which provides guidance to the different sections and contains relevant documentation available as Word documents.
Mental Capacity provides guidance on patients being able to consent to sharing & making advance decisions, again with relevant documentation.
Risk
This section is to aid you in recording any Risk of Harm to Self and Others or indeed from others, again coding and links to relevant risk assessment templates available.