Implementation guidelines for non-government community services

10.4 Assessment and review

Page last updated: 2010

Consumers receive a comprehensive, timely and accurate assessment and a regular review of progress is provided to the consumer and carer(s).

The intent of this standard is to ensure that the service providers collect, review and record information that is appropriate to the service type and consumer's individual needs and recovery goals. Assessment and review practices should reflect good practice in recovery oriented mental health and be conducted in collaboration with the consumer, and with the consumer's informed consent, their carer/s. Review practices should have progress towards achievement of the consumer's recovery goals as a primary focus.

Examples of appropriate information could include but are not limited to:

  • the consumer's service choices and recovery goals and how the consumer sees the services provided as contributing to the achievement of those goals
  • the consumer's diagnosis and history of previous mental health issues
  • details of present health and medical history
  • functional and emotional status, including the consumer's ability to communicate and care for themselves
  • level of risk the consumer presents to themselves and others
  • carer support arrangements
  • the consumer's knowledge of how to maintain a healthy lifestyle and reduce the risk of mental health problems
  • consumer's economic situation, social circumstances and level of education
  • individual circumstances of the needs of the consumer and carers that may affect service delivery
  • consent forms signed by the consumer and appropriate service provider staff
  • details of the integration of the service with other providers and arrangements for collaboration
  • the least restrictive environment within which services can be provided to the consumer
  • service exit plan.
Evidence that this criterion is met could include:
  • assessing and reviewing policies and procedures that have recovery as their primary focus
  • documentation on individual consumer files.
Assessment tools and methods (criterion 10.4.1)
Conduct of assessments (criteria 10.4.2, 10.4.3)
Planning discharge (criterion 10.4.4)
Review (criteria 10.4.5, 10.4.6) (partially applicable to the sector)
Follow-up (criterion 10.4.7 partially applicable to the sector)
Interdisciplinary care plan (criterion 10.4.8)

Assessment tools and methods (criterion 10.4.1)

Evidence based assessment tools and methods should be used as appropriate to the types of services provided. They could include individual service provider functional assessments, family input, suicide and other risk assessment, problem oriented assessment, formulation and mental status examination.

Evidence that this criterion is met could include:
  • assessing and reviewing policies and procedures that have recovery as their primary focus
  • the assessment methods and tools in use
  • documentation on individual consumer files. Top of page

Conduct of assessments (criteria 10.4.2, 10.4.3)

Assessments conducted during first contact are recorded in the consumer's individual health record. This should include information about:
  • service choices offered
  • recovery goals
  • the consumer's informed consent about what information will be shared by the service provider, and with whom and how it will be shared
  • the consumer's informed consent for information to be obtained from others
  • who was involved in the assessment, including the consumer, the referrer, other service providers and carer.
Information on informed consent is available in the guidelines for standard 1.

Wherever possible, and taking into account the service provider's staffing levels and risk assessment, the assessment should take place in the setting preferred by the consumer. Telephone and video technologies can be used when face-to-face assessment is not possible due to distance or the consumer's preference.

Evidence that these criteria are met could include:
  • assessing and reviewing policies and procedures that have recovery as their primary focus
  • the assessment methods and tools in use and the extent to which they support good practice in recovery
  • documentation on individual consumer files.

Planning discharge (criterion 10.4.4)

This criterion is not relevant to non-government community mental health service providers. Criterion 10.6 refers to service exit and re-entry. Top of page

Review (criteria 10.4.5, 10.4.6) (partially applicable to the sector)

Assessments should be regularly reviewed and updated. Reviews should be conducted in ways that are consistent with recovery-oriented mental practice. The particular requirements of a review depend on many factors such as the type or complexity of services provided, the consumer's recovery goals and collaborative arrangements that support the achievement of recovery goals.

Reviews should include re-assessment of identified risk and the least restrictive environment in which services can be provided. They should also include the extent to which mainstream community services can be utilised to support the consumer's continued progress.

Evidence that these criteria are met could include:
  • regular assessment reviews conducted at planned intervals, or at other times when there are significant changes in the consumer's circumstances or to the services provided - these should be documented in the consumer's individual health record
  • assessment reviews demonstrating progress towards recovery goals. Information on risk assessment is provided in the guidelines for standard 2.

Follow-up (criterion 10.4.7 partially applicable to the sector)

When a consumer declines the offer of service and the offer of assessment, the referring service should be advised. Support and referral should be offered to carers where applicable.

Evidence that this criterion is met could include:
  • documenting on referral forms that a referrer has been advised when a consumer declines an offered service. Top of page

Interdisciplinary care plan (criterion 10.4.8)

The care and recovery plan is developed with input from the consumer and, with the consumer's consent, carers and coordinator. It should contain details of the treatment and services provided.

It should also contain information on how the services being provided contribute to recovery goals, provide continuity of care and complement other treatment, and care and recovery plans developed by other service providers.

The age of consumers and carers will affect the degree to which they are involved in the development of their care and recovery plans. Care and recovery plans should be age appropriate especially where there are young carers. Child and adolescent consumers who experience problems within their family may have a legal guardian or others involved in their care and support who may need to be involved in the care plan.

Evidence that this criterion is met could include:
  • the assessment methods and tools in use and the extent to which they support good practice in recovery
  • documentation on individual consumer files
  • documenting that the consumer and, as appropriate, carers have received a copy of the current care and recovery plan and have been supported to ensure they understand the contents and that it addresses their needs and the consumer's recovery goals
  • consumer and carer feedback.