HLTH 1037 – Mental Health OSCA Assessment

TEMPLATE TO COMPLETE
HLTH 1037 – Mental Health OSCA Assessment 2
Complete the following ISBAR clinical handover as if you were the
Registered Nurse handing this client over to the next shift
ISBAR Clinical Handover
Identify the client:
Identify the client as much as you can. Name, age, gender DOB , MRN no#
The Patient’s name is Andy. He is a male, roughly in the late 20s.
Situation:
Presenting Issue – what is the main reason they have presented today? Current problems
* Recent Significant Events or Stressors – that may have contributed to the current presentation
* Symptoms (Sleep, Concentration, Energy, Appetite, Weight)
* Change in Frequency, Intensity, Duration of Symptoms
* Collateral – Information gained from other resources to support or refute the presentation
Client location ,status under Mental Health Act
The patient is redirected to a psychiatrist by the patient’s family doctor. The patient complains of abnormal
perception about the housemates, how they are associated with MI5 along with the university professor and
how they want to get him out.
The patient states that he has been suffering from stressing vents for the past two months. The patient
informs that he can hear sounds of housemates all the time even when they are not there. Andy states that
thoughts that are not of his own are being put into his mind by the housemates and complains watching
shows like Coronation Street that he would never watch on his own.
Duration of symptoms is 2 months, with no specific details mentioned for intensity of frequency of duration.
The patient is feeling insecure living with his housemates and is facing issue in concentrating. He has
reduced the intake of food due to fear of poisoning, indicative of increased appetite and reduced weight.
The patient states that his housemates have installed some kind of chip in his brain and are inputting
thoughts all the time. The chip is stated as tracking device and patient feels awkward sensation due to the
chip in his head.
The patients mention that he is having too much thoughts in the past couple of months and want to get rid
of them if possible.
The patient is not feeling safe eating food in the house, thinking it might have been poisoned by the
housemates and hence is eating less food.
Under the Mental Health Act 2015, the patient can be confirmed to have mental illness and is suffering from
psychotic disorder.
The mother of the client has requested the client to be redirected to psychiatrist by the doctor and has
presented that the client is facing distressing events.Background:
Current diagnosis if known
1. Diagnosis if known.
2. How / When / Why did the patient present to Hospital.
3. Relevant history / Physical health.
4. Medications and allergies.
5. Primary carer.
6. Accommodation.
* Current Living Situation / Accommodation
* Significant Relationships
* Developmental History
* Psychiatric History – previous history
* Current Medication – include all medication and herbal supplements
* Drug and Alcohol and Gambling History
* Family History – especially psychiatric history

* Previous Treatment / Medication
* Relevant Health / Medical Problems
* Domestic Violence
* Psychosocial
* Allergies – food as well as medication allergies
The patient is currently living with his two housemates in a different place, isolated from his family.
The patient feels comfortable in living with his mother, but does not want to do so as he thinks his
housemates might harm her.
No previous history of mental illness has been mentioned by the patient.
The patient has not been prescribed any medication.
The patient describes himself as general fit with no issues in physical health.
The patient does not drink much alcohol. The patient, however, smokes weed every day in high doses.
The patient states that he smokes 10 bags of weed every day approximately.
The patient admits injecting Amphetamines on weekly basis along with friends.
No psychiatric history of the family is presented.
The patient has no complains of domestic violence but fears that his housemates might harm him.
The patient’s psychosocial status is unhealthy with emotional and cognitive dysfunctionality. The patient
feels that he will be safe with his families, but fears that his housemates might harm them too. Moreover, he
believes that the housemates work for the MI5 and want to get him out. The client has thought of committing
suicide by overdosing on pills. The client keeps weapons such as knife and baseball bat with the intention of
harming the housemates. These are evident that the client is facing cognitive dysfunctionality.
Assessment:
In mental health settings clinicians would complete a Mental State Assessment in this section along with
noting the following points
* What are the current clinical signs
* Are they distressed, suicidal or at risk of harming others? For example threatening someone
* Are they engaged with the treatment plan? For example are they compliant with medication?
* What risks to self or others have been identified?
* Any changes to the patients status
1. A summary of the patients current condition or situation.
2. Clinical signs supporting the diagnosis.
3. Any signs of distress / Suicidal risk or harm to others.
4. Any planned diagnostic tests / Procedures Results from tests.
5. Is the patient / Carer engaged with the treatment plan.
6. What risks to self or others have been identified.
The patient is suffering from psychotic disorder. Clinical symptoms of the patient observed are
suspiciousness, difficult in concentrating, withdrawal from family, delusion, suicidal actions and thoughts.
The patient is severely distressed and is have had suicidal thoughts in the past. The patient thought of
committing suicide by overdose of pills.
The patient is at increased risk of harming others, especially the two housemates. The patient has kept a
baseball bat and knife in the room with the thought of harming the two housemates as they have been
disturbing him a lot recently.
The patient currently has not been prescribed any medication plans.
The patient has not voluntarily went for meetings with health care professional. After the meeting with
psychiatrist the patient seems to be more relaxed and open ups critical detail that will guide healthcare
professionals to adopt suitable intervention.
Recommendations:
Plan – what is the plan? immediate and short term, and possible long term plans