Alcohol

Illicit drugs

Self harm/OD

Psychosis

Depression/anxiety

Bi polar

dementia

Maternity

Somatoform

Delirium

Suicidal ideas

Personality disorder

Behaviour

Medication

Clozapine

Other (please specify)

From AWP Bed

CCG Area (GP location)

Wilts/Dorset/Somerset/Hamp/Other/NFA

Assessed

Yes/No Call back—Seen/declined/Not seen Inappropriate Ref *

Reason not assessed

Outcomes

(tick any that apply)

1 *

Discharged from MHLT—GP follow up

2 *

Home with advice for specialist out-patient referral (e.g. Drug and Alc/IAPT)

3 *

Secondary care—CMHT—already open

4 *

Secondary care—CMHT—New referral

5 *

Secondary care—Intensive Support—already open

6 *

Secondary care—Intensive Support—new referral

7 *

Other “specialist” mental health services (e.g. Memory team, Eating disorder/Perinatal/EI)

8 *

Psychiatric in-patient admission

9 *

Other—specify

10 *

Patient died

CGI-I: Clinical Global Impression—Improvement scale (not for one off contacts e.g. ED dept)

Very much Improved

Much Improved

Minimally Improved

No Change

Minimally Worse

Much Worse

Very Much Worse

1

2

3

4

5

6

7

IRAC Score

Specify main aim of contact (one only)

Assessment diagnosis/Formulation

1 *

Providing guidance/advice

2 *

Signposting/referring on

3 *

Assessment and management of risk

4 *

Assessment of mental capacity

5 *

Assessment Re: Mental Health Act

6 *

Medication Management

7 *

Management of disturbed behaviour

8 *

Brief psychological interventions

9 *

Treatment (other)

10 *