Legislation That
Guides Practice
Session Outline
• National Standards for Mental Health Services
2010
• Mental Health Act 2014
• Health Professionals Act (AHPRA)
National Standards for
Mental Health Services
The NSMHS focus on:
• how services are delivered
• whether they comply with policy directions
• whether they meet expected standards of
communication and consent
• whether they have procedures and practices in
place to monitor and govern particular
areas—especially those which may be
associated with risk to the consumer, or which
involve coercive interventions.
NSMHS examples:
Standard 7.
Carers
7.2 The MHS implements and maintains ongoing engagement
with carers as partners in the delivery of care as soon as
possible in all episodes of care.
Standard 10.
Delivery of care
10.1 Supporting recovery
10.1.1 The MHS actively supports and promotes recovery
oriented values and principles in its policies and practices.
Mental Health Act
2014
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What is in the Act?
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What is in the Act?
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Definitions
Objectives
Principles
Rights
Advance Statements
Nominated Persons
Assessment orders
Treatment orders
Variation
Revocation
Capacity
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Medical treatment
2nd psych opinion
ECT
Seclusion
Restraint (bodily)
Admin (chief psych)
MHT
Complaints
Security pts
Forensic pts
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Why do we need to know this?
10
Objectives of the Act
This Act has the following objectives—
• (a) to provide for the assessment of persons who
appear to have mental illness and the treatment of
persons who have mental illness;
• (b) to provide for persons to receive assessment and
treatment in the least restrictive way possible with
the least possible restrictions on human rights and
human dignity;
• (c) to protect the rights of persons receiving
assessment and treatment;
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Objectives of the Act (cont.)
• (d) to enable and support persons who have mental
illness or appear to have mental illness—
- (i) to make, or participate in, decisions about their
assessment, treatment and recovery; and
- (ii) to exercise their rights under this Act;
• (e) to provide oversight and safeguards in relation to
the assessment of persons who appear to have
mental illness and the treatment of persons who
have mental illness;
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Objectives of the Act (cont.)
• (f) to promote the recovery of persons who have
mental illness;
• (g) to ensure that persons who are assessed and
treated under this Act are informed of their rights
under this Act;
• (h) to recognise the role of carers in the assessment,
treatment and recovery of persons who have mental
illness.
13
Mental health principles
The MHA2014 lists 12 principles including, for
example:
• (d) persons receiving mental health services should be
allowed to make decisions about their assessment,
treatment and recovery that involve a degree of risk;
• (g) persons receiving mental health services should have
their individual needs (whether as to culture, language,
communication, age, disability, religion, gender, sexuality or
other matters) recognised and responded to;
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Four reform objectives
1. Recovery framework
2. Compulsory Treatment
3. Safeguards
4. Oversight and Service
Improvement
• Recovery Framework
• Compulsory Treatment
• Safeguards
• Oversight & Service Improvement
1. Recovery framework
• Recovery Framework
• Compulsory Treatment
• Safeguards
• Oversight & Service Improvement
2. Compulsory Treatment
Compulsory treatment
• An Assessment Order
• A Temporary Treatment Order
• A Treatment Order
MHA 101: Assessment Order
Completed by:
• MH practitioner
• Medical practitioner
Duration:
• 24 hr (up to 72 hr)
Purpose:
• Compulsory
Assessment
• Transport for
compulsory
assessment
MHA: 102 Receipt of a person subject to Inpatient AO
Completed by:
• Inpatient MH practitioner
• Inpatient medical
practitioner
Completed:
• As soon practicable after
admission
Purpose:
• Transfers Compulsory
Assessment Order to
Inpatient care
MHA 103 Variation of Assessment Order
Completed by:
• MH practitioner
• Medical practitioner
Duration:
• 24 hr (up to 72 hr)
from time of initial AO
Purpose:
• Varies Assessment
Order
– Outpatient to
inpatient
– Inpatient to
outpatient
MHA: 104 Extension of Assessment Order
Completed by:
• Authorised
psychiatrist (after pt
examination)
Duration:
• 24 hr (up to two
extensions permitted)
Purpose:
• Allows compulsory
assessment to be
postponed on clinical
grounds
MHA 105: Revocation of Assessment Order
Completed by:
• Authorised
psychiatrist (after pt
examination)
Determination:
Patient does not meet
criteria for
compulsory
treatment
Purpose:
• Ceases compulsory
episode
MHA 110:Temporary Treatment Order
Completed by:
• Authorised psychiatrist
(provided they have
not also made the AO)
Duration:
• Maximum 28 days
Determination:
• Patient meets criteria
for compulsory
treatment
Purpose:
• Permits compulsory
treatment to begin
MHA 111:Variation of TTO or TO
Completed by:
• Authorised psychiatrist
(after pt examination)
Duration:
• Max 28 days (TTO)
• As stated on TO
Purpose:
• Varies Treatment Order
from
– Outpatient to inpatient
– Inpatient to outpatient
MHA 112 Revocation of TTO or TO
Completed by:
• Authorised
psychiatrist (after pt
examination)
Determination:
Patient no longer
meets criteria for
compulsory
treatment
Purpose:
• Ceases compulsory
treatment episode
MHA 113 Application for Treatment Order
Completed by:
• Authorised
psychiatrist (after pt
examination)
Determination:
Patient continues to
meet criteria for
compulsory
treatment
Purpose:
• Continue
compulsory
treatment episode
MHA 114 Application to the Mental Health Tribunal
Completed by:
Compulsory Patient
When:
Patient discretion
Purpose:
Patient initiated
application against
(MHA 1986 “appeal”)
1. Compulsory treatment
order
2. Transfer of care
3. Refusal to grant leave of
absence
• Recovery Framework
• Compulsory Treatment
• Safeguards
• Oversight & Service Improvement
3. Safeguards
MHA 131: Consent form to ECT
Completed by:
• Patient or person
receiving ECT
When:
• Following medical
examination by AP who
is satisfied patient has
capacity
• Prior to commence of
ECT
Purpose:
• Permits ECT to begin
maximum 12 treatments
over a maximum 6
months
MHA 132: Application for ECT
Completed by:
• Authorised psychiatrist
When:
• Where a patient is
unwilling or does not
have capacity to
consent to ECT
• ECT is considered the
least restrictive
treatment option
Purpose:
• Begins the process for a
MHT ECT
determination
Restrictive interventions
Bodily restraint definition MHA 2014:
• “..a form of physical or mechanical restraint that
prevents a person having free movement of his or her
limbs, but does not include the use of furniture
(including beds with cot sides and chairs with tables
fitted on their arms) that restricts the person's ability to
get off the furniture.”
Seclusion definition MHA 2014:
• “..the sole confinement of a person to a room or any
other enclosed space from which it is not within the
control of the person confined to leave.”
MHA 140:Authority for restrictive intervention
Completed by:
• Authorised Psychiatrist
• Medical Practitioner
• Senior nurse on duty
Determination:
• Patient requires restraint to
prevent risk to self/others or
administer treatment
Purpose:
• Permits use of physical,
mechanical restraint or seclusion
MHA 141: approval for urgent physical restraint
Completed by:
•
Registered Nurse
When:
•
•
In the event of a psychiatric emergency
to prevent harm to a person or others
AP, medical practitioner or senior nurse
on duty not available to authorise
Purpose:
•
Allows physical restraint to occur until
– emergency has past
– Medical/ senior nursing staff
consider MHA 140 criteria is
required
MHA 142: Restrictive interventions observations
Completed by:
• Medical Practitioner
• Registered nurse
When:
• During an episode of
restrictive intervention
Purpose:
• Ensure monitoring of
patient during restrictive
intervention episode
Health Professionals Registration Act
2005
What does this ACT encompass?
• In Victoria, there are twelve health
practitioner registration boards that
operate under the Health Professions
Registration Act 2005. These boards are
independent, self-funding statutory
authorities.
• Commonly known as AHPRA
What is this new ACT?
• The primary purpose of the Health Professions
Registration Act 2005 is to protect the public
by providing for the registration of suitably
qualified health practitioners, the
investigation of the conduct and fitness to
practise of registered health practitioners and
the issue of guidelines and standards relevant
to the profession.
Which professionals are bound by this
ACT?
Chinese Medicine Registration Board of Victoria
Chiropractors Registration Board of Victoria
Dental Practice Board of Victoria
Medical Practitioners Board of Victoria
Medical Radiation Practitioners Board
Nurses Board of Victoria
Optometrists Registration Board of Victoria
Osteopaths Registration Board of Victoria
Pharmacy Board of Victoria
Physiotherapists Registration Board of Victoria
Podiatrists Registration Board of Victoria
Psychologists Registration Board of Victoria
Occupational Therapists came under the ACT in 2012
Implications on practice
• http://www.nursingmidwiferyboard.gov.au/Codes-GuidelinesStatements/Professional-standards.aspx
• Professional boundaries for nurses
Code of Ethics for Nurses
1. Nurses value quality nursing care for all people.
2. Nurses value respect and kindness for self and others.
3. Nurses value the diversity of people.
4. Nurses value access to quality nursing and health care
for all people.
5. Nurses value informed decision-making.
6. Nurses value a culture of safety in nursing and health
care.
7. Nurses value ethical management of information.
8. Nurses value a socially, economically and ecologically
sustainable environment promoting health and
Wellbeing.
Code of Professional Conduct for Nurses
1. Nurses practise in a safe and competent manner.
2. Nurses practise in accordance with the standards of
the profession and broader health system.
3. Nurses practise and conduct themselves in
accordance with laws relevant to the profession and
practice of nursing.
4. Nurses respect the dignity, culture, ethnicity, values
and beliefs of people receiving care and treatment,
and of their colleagues.
5. Nurses treat personal information obtained in a
professional capacity as private and confidential.
Code of Professional Conduct for Nurses
6. Nurses provide impartial, honest and accurate
information in relation to nursing care and health
care products.
7. Nurses support the health, wellbeing and informed
decision-making of people requiring or receiving
care.
8. Nurses promote and preserve the trust and privilege
inherent in the relationship between nurses and
people receiving care.
9. Nurses maintain and build on the community’s trust
and confidence in the nursing profession.
10. Nurses practise nursing reflectively and ethically.
Unprofessional Conduct
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Lesser standard
Professional misconduct
Finding of guilt
Failure to act when required
Contravention of the Act
How are Complaints Investigated?
• Must be in writing
• See regulations
• Legal support
Investigations/Hearings
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Professional conduct
Informal hearing
Formal hearing
Process for investigations into professional
conducts
Clinician responsibility
• Clinicians will need to provide evidence of ongoing
professional development activities – random
auditing of individual nurses to provide evidence of
PD
• This will be linked to eligibility to practice
• Scope of practice will broaden – especially for Div 2
nurses(SEN’s)- no longer are they to be under the
“supervision of Div1/3” but accountable for their
own practice.
• Establishment of a National Nursing Register to make
cross boarder employment easier.
Documentation and the Health
Records Act
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What is a Medical Record
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Why Document?
• The making of notes is a fundamental
communication exercise in health care.
• Notes often form the basis for further
communication between team members, and across
time in dealing consumers.
• Written reports constitute an ongoing account of the
consumer’s stay in hospital.
• And, from time to time, a consumer’s medical
records will be required as evidence in court.
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Electronic Medical Records
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Some services have electronic medical records
Principles of good practice remain identical
Process is different for each service
It is your responsibility to know the policies of
your service and adhere to them
Reports as Evidence
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Considerations
The ABC of report writing:
• Accuracy
• Brevity
• Completeness
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Accuracy
• It is important to
distinguish between what is
personally observed and
what is related as part of a
consumer’s complaint of
illness or injury.
• Unless the assault was
actually witnessed, the
consumer’s complaint of
injury is clearly hearsay and
must be reported as such.
The difference in the
record between
writing:
“Consumer
assaulted by two
men”
and
“Consumer reported
that he had been
assaulted by two
men”.
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Brevity
• Avoid unnecessary
verbosity
“If the style of your report writing
utilises overly long sentences,
or, as is sometimes the case,
complex sentence structure
with multiple items of
information, the salient
message intending to be
conveyed can ultimately be
dissipated and obfuscated
causing, not only confusion for
the reader, but on those
occasions where the author
loses grammatical and
syntactical control.”
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Completeness
• As part of ensuring
If a consumer had been
the reports are
advised to remain on
complete, reference
complete bed rest,
should always be
the fact that the
made where a
consumer refuses any consumer insisted on
getting out of bed to
treatment or
go to the toilet should
medication or acts in
be recorded.
a manner contrary to
advice.
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Completeness
To identify how often and how detailed documentation
should be consider:
1.
2.
3.
4.
The complexity of the consumer’s needs
The degree that the consumer’s condition, care or
treatment puts them at risk
Policies and legal requirements in your clinical setting
Any unusual events: such as transfer, refusal of treatment,
accidents, non attendance for appointments etc.
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Standards for Writing in the Medical Record
 As per your own Medical Record
Documentation Policy, entries must be:
w legible.
w signed, with the name and designation of the
author printed.
w dated fully with the time of entry printed
w in either black or blue pen.
All entries in the medical record, including
alterations to the record must be legible.
64
Standards for Writing in the Medical Record
• Write the DATE and TIME of entry
• Your profession (Nursing, Allied Health,
HMO)
•Reason for entry(i.e. Nursing Entry, Case
manger Entry, Statutory Review, Clinical
review) at the start of your entry.
65
Standards for Writing in the Medical Record
• If documenting a serious event for example
absconded consumer, severe self-harm,
serious attempt or actual suicide include the
actual time of the incident (i.e. 7.35pm) and a
chronological account of incident and
subsequent management including outcome.
66
Standards for Writing in the Medical Record
• At the end of your entry SIGN, PRINT YOUR
INITIAL&SURNAME and DESIGNATION (i.e. RPN,
Psychologist).
• This is very important because each entry is an
account of your actions and will be read by others to
ensure that care provided at that time was
appropriate etc. i.e. Treating team, Case Managers,
Coroner.
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Standards for Writing in the Medical Record
• Use a label on EVERY progress note.
Each sheet within the medical record
should be identified with the client label.
• When using a label, ensure the label is for
the correct consumer, and that the label
has the current details on it.
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Standards for Writing in the Medical Record
When you provide a consumer or family with
RIGHTS brochure or other pamphlets i.e.
psycho educational material, RECORD it
in the progress notes or management
plan. (If this is not documented it did not
happen)
69
Standards for Writing in the Medical Record
Highlighters/ fluorescent markers should
not be used at all in the medical record
because of reduced reproducibility. they
don’t transfer into other mediums e.g.:
fax, photocopy or microfilm)
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Standards for Writing in the Medical Record
• Entries should be made in black or blue
pen. Pencil and fountain pens should not
be used.
• PRN medication to be underlined, with
reason required and effects. Not written in
red or highlighted. As these mediums do
not reproduce well in faxes, photocopies
or microfilm.
• No correction fluid is to be used.
71
Standards for Writing in the Medical Record
 A single horizontal line must rule out
errors. This must be signed and dated with
an explanatory statement i.e. wrong
consumer, wrong medical record.(process
will be different if you make an error on the
electronic record)
• The same process is used for an unused
space on the progress notes. It is not
necessary to sign for unused space.
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Standards for Writing in the Medical Record
• Personal, offensive or humorous comments about
consumers should not be written in the medical
record. The medical record is a legal document
developed for consumer care. It communicates
between health professionals. The FOI Act governs
us, and inappropriate comments may be released at
a later stage to the client or another party.
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Standards for Writing in the Medical Record
• Progress notes, medical, nursing and allied
health staff to record all significant events
must document observations and consultation
reports.
• Only abbreviations and symbols acceptable to
the facility are used.
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Standards for Writing in the Medical Record
• Entries into the medical record must be made
as close as possible to the time of occurrence
of the event(s) being documented.
• All student entries must be countersigned by
their supervisor.
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FOI Exempt
•
Freedom of
Information (FOI)
exempt entries
must be indicated
with a vertical line
drawn along the
outside margin. At
the top of the entry
write “FOI Exempt”
inside a box.
08.02.08
FOI Exempt
1000
hrs.
Nursing Entry: P/C from Judy’s
Mother concerned that Judy spent
most of her ONL smoking marijuana
in her room. Mother feels that if Judy
is aware of her contact with the unit
it will jeopardise her already fragile
relationship with Judy. Judy has been
threatening mother with physical
violence is she is kept in hospital any
longer than is necessary.
John Hicks RPN3
76
The Progress Notes
• Documentation is to provide a mental status examination,
response to treatment and the rationale for treatment within
each entry.
• All nursing interventions are to be documented
• Care provided over the shift and review of treatment plan as
appropriate to be included
• On Inpatient units this is done for each shift. The night shift is
not expected to follow the same format, as they are limited in
their engagement with the client.
• In the community it is done for each contact with or with any
information obtained regarding that client
77
The Progress Notes
• In all entries, issues relating to Nursing Management
/Treatment Plan / Consumer Goal Plan.
w Mental status assessment should include:
•
•
•
•
•
•
•
•
•
•
Presentation/ Appearance,
Behavior and psychomotor activity,
Affect/Mood,
Thought disturbance,
Thought content,
Perceptual disorders (including whether they are hallucinations,
delusions, whether they are self reported/observed, third party
report, congruent with affect),
Insight/Judgment,
Cognition/Concentration/Consciousness/Memory,
Risks including category observations.
Include Sleep, Diet/Appetite.
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The Progress Notes
• Record any activities out of the norm that is not
part of the nursing management plan/ISP (i.e.:
AWOL, MHRB, transferred to ECU, Family
meeting etc.)
• Record any action or future activity that needs to
take place (i.e.: appointments to be made,
referrals etc.)
• Each entry is to start with the discipline, date
and time of entry and conclude with signature,
printed name and designation.
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When records are poor: Implications for
nurses.
• The (unfortunately fairly common) occurrence of inaccuracy
in the nurses’ records elicits considerable irritation in the
judicial arena. Although medical records have also been the
objects of judicial criticism, there is a stronger written culture
in medicine and thus perhaps a tendency to greater accuracy.
This has often enabled their records, and thus their evidence,
to carry more weight than those of nurses.
• Nursing staff should place a great deal of importance on
recording their entries in an accurate, objective and timely
manner.
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Points to remember.
• Always document all care and treatment provided to your
consumer each shift/or for each contact.
• Be clear in your intention regarding the manner in which you
make your entry.
• Your records will be read by others (team members, coroner,
civil proceedings etc.)
• Omission of any details regardless of how experienced you are
as a nurse will not stand up in court.
• “Document, Document, Document”
• If it is not recorded it did not happen.
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Tips the “F.A.C.T.U.A.L”
Method
•
•
•
•
•
•
•
F = focused on the consumer
A = Accurate
C= Complete
T = Timely
U= Understandable
A= Always objective
L= Legible
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Professional Misconduct &
Documentation
•
•
•
1.
2.
3.
4.
Failure to keep records as required
Inappropriate destruction of documentation
Falsification of clinical records:
Documenting care that never occurred
Signing a document that is known to contain false or
misleading information
Signing for care that was carried out by another person
In relation to medication- signing to the disposal of
controlled drugs when the act was not witnessed
84
References
• 1. Australian Council of Healthcare
Standards - Information Management
standards
• 2. Australian Council on Healthcare
Standards - Continuum of Care standards
• 3. National Standards for Mental Health
Services - Standard 10 Documentation
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