Documentation & the MSE
1 CNE point
Good documentation – good defence
Poor documentation – poor defence
No documentation – no defence
Objectives - Documentation
Participants will:
• have a greater appreciation / understanding of
the need of accurate documentation in the
mental health setting
• be able to demonstrate use of the
documentation framework presented
• have a great awareness of professional
accountability and documentation
Objectives - MSE
• to visit/revisit the essential components of an
MSE
• to consolidate current knowledge of conducting
and interpreting an MSE
• to practice conducting and writing up an MSE
Increased awareness and curiosity
• about the language used
• messages, interpretations and meanings
provoked and transferred in the documentation
Problem based and
solution focused
Documentation
Reflects the professionalism, competence,
respect for patients and their families and the
degree of competence with the policies and
procedures of the workplace
(Navuluri, 2001)
The quality of documentation can determine
whether a malpractice attorney accepts or
declines a suicide case
(Simpson & Stacy, 2004)
Benefits to the client
• Ensures the client is consulted and included in
their care planning and that their decisions are
recorded
• Supports continuity of care – allows
professionals involved in care to safely take
over the clients ongoing care
• Gives useful historical information for future care
• Provide a legal document of the care they
received (QNC, 2005)
Benefits to the health professional
• Gives clear and dependable instructions
• Highlights unique contribution to care
• Increases professional credibility by recording
clinical judgement, delegation decisions and
critical thinking
• Involves a structured reflective reasoning process
(identifying an emerging pattern)
• Saves time – less energy spent searching for
information/instructions
• Provides reliable, accurate and complete
information for safe and effective care & treatment
(QNC, 2005)
Benefits to organisation
• Provides complete & reliable data
to justify financial expenditure and
resource allocation such as staffing levels
and equipment
• Facilitates research, auditing and quality
improvement processes
(QNC, 2005)
F.A.C.T.U.A.L.
Focused on the client
Accurate
Complete
Timely
Understandable
Always objective
Legible
(QNC, 2005)
Patient settled ATOR
Patient more settled today, less intrusive. S/B S.W.
today. Spending time in courtyard. Plans to go to
local shops today
Patient given 1:1 time. Pt struggling and reports low
mood. Pt reactive throughout 1:1. Pt continues to
use CBT techniques from last admission and is
able to stop irrational thoughts. Encouraged patient
to seek support.
Reported increase in suicidal thoughts (no intent)
early in the shift but these subsided following prn
diazepam. Superficial conversation with staff only
M S E ..is
• Used as a screening tool to assess an
individuals current neurological &
psychological status
• A means to transfer knowledge and
clinical practice
• A guide to individuals presentation and
progress
• Involves observations as well as an
interview
• Assess safety
Important part of treatment planning
MSE
• Appearance & Behaviour
• Speech
• Mood & Affect
• Thought content /
processes
• Perception
• Insight & Judgement
• Sensorium & cognition
• Safety
Appearance & Behaviour
• Describe the individuals physical
appearance (grooming, hygiene, clothing, nails,
build, tattoos, piercing)
• Individuals reaction to your interaction/
being admitted / present situation (hostile,
friendly, grandiose, withdrawn, uncommunicative,
seductive)
• Motor behaviour (psychomotor retardation,
restless, repetitive behaviours, hyperactive, tremor, hand
wringing bizarre, agitated, anxious)
Speech
Rate (slow, accelerated,
normal)
Volume (loud, soft, whispered)
Quantity of information
Mutism (absence of speech)
Poverty of speech (responses
brief & monosyllabic)
Pressure of speech (rapid,
difficult to interrupt, loud and
hard to understanding)
Mood
Defined in the Diagnostic and Statistical Manual of Mental
Disorders IV (DSM IV) “is a pervasive and sustained
emotion that colours the perception of the world.
Variations in mood occur as a normal response to specific
life experiences. Those responses are transient and are
not associated with significant functional impairment such
as depression elation, anger, and, anxiety”.
• With a mood disorder: “the individual has persistent or
recurrent disturbances or alterations in mood that
continually cause psychological stress and behavioural
impairment over the year” (Boyd & Nihart 1998:439).
• Internal feeling or emotion – often influences behaviour
Depressed, labile, euphoric, fearful,
hostile, anxious, dysphoric, euthymic
What about……
exhausted, confused, ecstatic, guilty, confident
shy, bored, surprised, overwhelmed,
embarrassed, thoughtful, relived, impressed,
determined
Affect
- the observable
expression of
emotion
- striated muscles
controlling face,
posture, vocalization
(Nathanson, 1992)
Reactive (normal)
Restricted (decreased intensity
& range)
Blunted (severe decease in
intensity & range of emotional
expression)
Flat (almost complete or
complete absence of emotional
expression - usually
accompanied with monotonous
voice)
What about …..
Interest, excitement, enjoyment
Surprised, startled
Shame, humiliation
Dissmell, disgust
Fear, terror
Distress, anguish
Anger, rage
(Nathanson, 1992;Tomkins, 1963)
Thought content
Amount of thought and rate of production
– Poverty of ideas
– Flight of ideas
– Slow/hesitant thinking
– Vague
Continuity of ideas
– Logical order
– Tangential
Disturbance in language
– New words
– Conversations that do not make sense
Thought processes
Thought blocking
Neologism
Fragmentation
Perseveration
Flight of ideas
Word Salad
Confabulation
Circumstantiality
Loose associations
Tangentiality
Thought Content
Delusions
– Fixed beliefs (grandiosity, jealousy, fantastic,
nihilistic, religious)
Suicidal thoughts
– Transient, intrusive, persistent
– Plan
Other
– Obsessions, antisocial urges,
hypochondriacal
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Delusions of persecution
Delusional mood
Delusions of reference
Delusions of control, influence or
passivity
Religious delusion
Nihilistic beliefs
Fantastic delusions
Delusions of jealousy
Grandiose delusions
Perception
Hallucinations
auditory
visual
olfactory
gustatory
tactile
somatic
Derealisation
Depersonalisation
Heightened
perception
Dulled perception
Insight & Judgement
Judgement
During the course of an assessment many aspects of the individuals capacity
for social judgment may be obvious. The clinician has to make an
assessment on whether or not the individual has the ability and capacity
to self assess what is happening around them and to make important
discussions in their own best interests.
Insight
Refers to the DEGREE of awareness and
understanding that the person has that she/he is ill.
May be total denial. Some awareness but still denying.
Awareness of illness but blaming on others.
Acknowledge the illness but ascribe it to
some unknown illness or event.
Sensorium & cognition
Attention and concentration
• Provides an assessment on
whether the person is alert and
able to follow the interview or
whether they are easily
distracted by other things
happening around them.
Poor concentration
• May be due to inefficiency of
thinking, distractability, anxiety,
delusions etc. (Assessment
tool named Serial 7’s can be
used to assess concentration –
ask person to subtract from
100 by 7’s - how far can they
go).
Orientation
• To time, place and person
• True disturbances in
orientation are found only in
organic mental disorders.
Memory - loss of:
• Immediate (recall and
retention) (give your name,
date 10 mins later can the
person recall)
• Recent (what did they have for
breakfast? what did they do
yesterday?)
• Remote (ask questions about
persons childhood, important
events in their life)
General knowledge
How is the person at counting, telling the time,
naming the prime minister, what is the latest news
Abstract thinking
Generally assessed by asking the person to interpret proverbs
(i.e. a rolling stone gathers no moss). However this can be difficult
to assess based on persons intelligence, culture, language, beliefs.
The presentation of changes to one or more of those process
(attention, concentration, thinking etc) may be caused by a
number of factors such as physical complications:
(tumour, infection, or pain); influence of drugs
(prescribed and non prescribed, or alcohol),
post effects of poisoning deliberate or non deliberate:
Safety
Suicidal, homicidal, self harm and
impulsive thinking – behaviour are
important in the area of MSE
Consider also safety in terms of vulnerability
(sexual activity – consumer/consumer,
consumer/staff member, consumer/external
other)
Other safety considerations include: AWOL
physical risks, child safety
MSE (or CP)
Presenting a picture of the patients
presentation to the reader
A Attending to ADL’s. Casual attire Socialising with peers, engaging with staff,
good eye contact, participating in groups today (self esteem)
S Normal rate and flow
M describes mood as “low”, rates on scale of 1-10 as 3
states that her mood “gets better as day progresses” and
last night scored her mood as 6 Reactive affect in conversation
T States that she has been “experiencing thoughts of self harm especially in the
mornings”. States does not want to “self harm whilst in hospital” “want to try
the new strategies that I have been learning”
No obvious thought disturbances voiced or observed during interaction
P No obvious perceptual disturbance observed or voiced during interaction
I During interaction patient demonstrated insight about her admission and about
her self harm thoughts. Pt. has the capacity to self assess as demonstrated in
behaviour not to follow through with self harm thoughts
S Patient alert, short and long term memory intact, able to engage in a
conversation for 30 mins
S Patient has stated that she has felt safe this morning and has not experienced
any suicidal or self harm thoughts to time of report
Interventions
Tell the reader what you did
• Staff time – 30 mins
• Discussed with patient the issues they were concerned
about (family, work)
• Encouraged patient to identify strategies to manage
concerns (journaling, discuss concerns with partner)
• Developed with patient hierarchy of self harm reduction
strategies (same attached to front of chart)
• Accompanied patient on walk round hospital grounds observed interest patient expressed in physical
surroundings
• Patient offered PRN medication
Outcomes
Inform the reader about the effectiveness of
the interventions that you used
• Patient’s safety maintained throughout shift
• Patient’s level of distress increased following discussion
and patient has verbally stated that they are not suicidal
and will approach staff if they are feeling unsafe and
wish staff time and or prn medication,
• Patient maintained on 30/60 visual obs
• Dr Blogg’s informed re patients progress/status
In summary
• Be guided by policies of organisation
• Be aware of the value of your
documentation
• Be thoughtful of what you write and how
you write it
• Be aware that patients can access their
notes – include them in your readership
• Initially takes time to use the framework –
easier with practice
Preparing for discharge …
What is the individuals wishes ……?
References
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Elder, R., Evans, D, & Nizette, D. (2004). Psychiatric and Mental Health
Nursing. Elsevier Australia: Marrickville.
Navuluri, R. (2001). Documentation: What, why, where, who and how?
Research for Nursing Practice, 3(1). Retrieved 10 August 2006 from
http://www.ateresearch.com/Navu-Docu.htm
Nathanson, D.L. (1992). Shame and pride. Affect, sex, and the birth of the
self. New York: W.W. Norton & Company.
Queensland Nursing Council. (2005). Professional documentation
standards. Framework Information Sheet No 3.
Simpson, S., & Stacy, M. (2004). Avoiding the malpractice snare:
Documenting suicide risk assessment. Journal of Psychiatric Practice, 10,
185-189.
Tomkins, S. (1963). Affect, imagery, consciousness. Vol 2. The negative
affects. New York: Springer.
Sanders, M. R., Mitchell, C., & Byrne, G. J. A. (Eds.) Medical Consultation
Skills. Behavioural and Interpersonal Dimensions of Health Care. AddisonWesley: South Melbourne.