Report outlining a treatment plan for a mentally disordered patient who has just arrived within a medium secure hospital.
A 33-year-old female with a diagnosis of schizophrenia, and a history of self-harming behaviour. The patient has a history of assault on staff and patients, and is considered a revolving door patient. The offense resulting in the section was theft and antisocial behaviour. Officers on scene were concerned for the patients safety at the time of arrest.
he report must be written with a mixed audience in mind. This can include GPs, Psychologists, Psychiatrists, Nurses and Support Workers. Due to the mixed audience of those reading the reports, try to structure your ideas in a clear, practical, concise, and easy to understand format (for example, it may be appropriate to use additional sub-headings to help illustrate your ideas).
The report must contain the following sections:
Case overview (100-300 words) – This section must be a compressive overview of the patient’s history, triggers for maladaptive behaviours, and their current difficulties.
Risk assessment and diagnoses – This must include the current and past risk of the patient. Any future assessments that you recommend should be justified here.
Treatment and interventions – This section must include an overview of past treatment, intervention, and engagement. Recommendations for future plans should be included.
Long term plan (100-300 words) – This must include a pathway to either a community placement, lower level of secure service, or prison. Remember to include recommendations for intervention and treatment.
