Brief task description
Develop an ability to observe consumer behaviour and accurately document those observations as findings on the Mental Status Examination (MSE) and risk screening tool in the correct assessment categories using the correct terminology. You will also develop patient-focused documentation skills in reporting the identified MSE and risk assessment findings concisely and accurately within the nursing report.
Please include the following consumer details on the appropriate documentation for this assignment.
- Read the history related to Peter Goldblum.
- Access and download the MSE form and risk screening tool from the study desk. “MSE Form & Risk Screening Tool.” The MSE is a word document, and you are required to type directly into the formatted document provided.
- From the information obtained from Peter and documented on the MSE, a risk assessment is also to be completed using a Risk Screening Tool (separate from the MSE that you will complete). The risk screening tool is available via the study desk. Print both sides of the risk screening tool form and complete the assessment in your own hand writing. As this form must be handwritten, writing must be legible for marking and no other risk assessment form will be accepted.
- Watch the video about Peter that is located on the study desk. Record your observations from the interview/assessment between Peter and the mental health consultant, on the MSE form. Refer to your text and lectures throughout the semester on the study desk for assistance, ensuring that you use the appropriate mental health terminology to communicate your findings.
- You may record findings in dot point or in a short paragraph, however, you must support and specify the evidence that substantiates your observation,e.g. paranoia as Peter believed that he was being followed as evidenced by…..
The MSE report is to be typed as a word document, be succinct and relevant to your findings that were included in the interview content.
- From the findings and documentation in the MSE or Risk Assessment screening for Peter, identify 3 relevant symptoms or issues that Peter displayed during the interview, or is recorded on the Risk Assessment.
- Research two (2) evidenced-based nursing mental health interventions per finding / symptom to assist you in completing the management plan for Peter.
- Complete the symptoms / findings and intervention page. There should be 3 symptoms / findings in total identified, and 2 evidenced mental health nursing-based interventions per symptom (total of six interventions) and one reference per intervention to a total of six individual references.
- The symptoms / findings that you record on your intervention page, must be from documented evidence within your MSE and or risk assessment report.
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