RISK ASSESSMENT
Protocol
MENTAL HEALTH & ADDICTION SERVICES
MHAS.A1.44
MENTAL HEALTH & ADDICTION
SERVICES PROTOCOL
STANDARD
It is the Bay of Plenty District Health Board (BOPDHB) Mental Health & Addiction Service’s
(MH&AS) policy intent that that all clients receiving care will have a formal Risk Assessment
completed and an individualised Risk Management Plan identified within the Treatment Plan.
OBJECTIVE
To provide clear safe guidelines to assist mental health clinicians to better assess and
manage Clinical Risk in MH&AS.
To minimise the likelihood of an adverse outcome.
To ensure effective monitoring systems to detect early warning signs and ready access to
services if need be.
To meet the New Zealand Health & Disability Services Standards.
To ensure compliance with Occupational Health and Safety requirements.
STANDARDS TO BE MET
1. Risk Assessment
1.1.
All clients of the MH&AS will have a Risk Assessment completed, based on
accurate information, using the risk assessment form and guidelines, as part of
their comprehensive assessment (see Assessment Protocol MHAS.A1.23).
1.2.
Those individuals entering the service in crisis or acutely will have their risk
assessed
immediately
including
the
risks
evident
for
substance
impaired/intoxicated individuals. Full risk assessment will be completed within four
(4) hours by those people involved in the comprehensive assessment.
1.3.
A full Risk Assessment not able to be completed with the clients informed consent
due to the consumers level of substance induced intoxication, will be undertaken at
the first practicable opportunity once the level of substance impairment has
adequately reduced
1.4.
Completion of risk assessment for non-acute individuals is the responsibility of the
multi-disciplinary team (MDT) and will be carried out by the most appropriate team
member, e.g. Nurse, Social Worker, Occupational Therapist (OT), Psychologist or
Medical Officer.
1.5.
The Risk Assessment will be based on factual information, informed opinion,
clinical assessment and thorough collection of accurate information covering all
aspects of the illness, background, behaviour and individual circumstances.
1.6.
Risk Assessments will be easily and quickly accessible at the front of the
consumer’s health record and made available on entry to all parts of the service.
The risk assessment will follow the client through the service.
1.7.
The risk assessment can be updated at any time. Amendments should be
documented on the form and in the consumer’s health record.
1.8.
Risk assessments will be reviewed at defined intervals by members of the MDT
and the findings documented in the consumer’s health record and on the form.
This should take place no less than every three (3) months.
Issue Date:
Sep 2015
Page 1 of 4
NOTE: The electronic version of
Review Date:
Sep 2018
Version No: 5
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Business Leader &
assumed to be the current version.
Safety Coordinator, MH&AS
Clinical Director, MH&AS
RISK ASSESSMENT
Protocol
MENTAL HEALTH & ADDICTION SERVICES
MHAS.A1.44
MENTAL HEALTH & ADDICTION
SERVICES PROTOCOL
1.9.
Clients will be aware of their rights and these will be observed wherever possible.
1.10. The client, family / whanau and others nominated by the client will be consulted in
the risk assessment; if this does not occur then the reasons why will be
documented.
2. Risk Management
2.1
All clients will have a treatment plan (includes risk management) that is informed
by data gathered in the risk assessment and comprehensive assessment. The
aim of this is to prevent escalation of challenging or ‘risky’ behaviour / situations
(e.g. children at risk) by prevention, minimisation and management of risk.
2.2
The management of risk wil be part of the individual’s treatment plan, and the
designated nurse / case manager or other clinician will implement the plan as soon
as it is practical to do so.
2.3
The management of risk should address:
a)
Immediate risks
b)
Identify ongoing management
c)
Future preventative actions.
d)
Challenging behaviour and strategies to deal with this
e)
The context, opportunity, means and motivation of the individual
2.4
The client and nominated whanau / support will be consulted in the planning of risk
management and consulted regarding ongoing care and review.
2.5
Risk Assessments and treatment plans must be readily available to other teams /
individuals involved in the clients care to ensure appropriate care and minimisation
of risk.
2.6
The risk assessment will be formally reviewed at defined intervals, as part of an
ongoing review of the individual risk assessment / treatment plan. The treatment
plan will be revised accordingly and new outcomes identified.
2.7
The risk assessment can be updated at any time and changes noted in the
consumer’s health record and on the treatment plan. Entries to the treatment plan
must be dated and signed.
3. Cumulative History of Risk
3.1
Will be commenced at the time of initial comprehensive assessment and risk
assessment and will be updated with any new hazardous behaviour identified, or
prior to new risk assessment form being commenced i.e. after four (4) review
periods if any further additional information.
Issue Date:
Sep 2015
Page 2 of 4
NOTE: The electronic version of
Review Date:
Sep 2018
Version No: 5
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Business Leader &
assumed to be the current version.
Safety Coordinator, MH&AS
Clinical Director, MH&AS
RISK ASSESSMENT
Protocol
MENTAL HEALTH & ADDICTION SERVICES
MHAS.A1.44
MENTAL HEALTH & ADDICTION
SERVICES PROTOCOL
PROCEDURE
FLOW CHART--RISK ASSESSMENT
PROCESS
TASKS/STANDARDS
WHO
Within 4 hours of entry
Information gathered from client,
ASSESSMENT OF RISK
whanau, etc
ACUTE
HEALTH CARE
Complete appropriate form
PROFESSIONAL
Re-Assess at first practicable
opportunity if original Risk
Assessment compromised by
consumers level of intoxication
Information gathered in conjuction
with multidisciplinary team, client
EXISTING .
CASE MANAGER
and whanau
Complete appropriate form
Summarise assessment data
Identify risk factors
FORMULATION OF RISK
REGISTERED NURSE OR
Identify early warning signs and
MANAGEMENT PLAN
CASE MANAGER
potential strategies for ongoing
management and reduction of risk
REGISTERED NURSE OR
IMPLEMENTATION
Implement Risk Management Plan
CASE MANAGER
Review of plan and assessment at
REGISTERED NURSE OR
REVIEW
defined intervals os outlined in
CASE MANAGER
policy standards
Update documentation of forms as
REGISTERED NURSE OR
UPDATE
required--an ongoing process
CASE MANAGER
Issue Date:
Sep 2015
Page 3 of 4
NOTE: The electronic version of
Review Date:
Sep 2018
Version No: 5
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Business Leader &
assumed to be the current version.
Safety Coordinator, MH&AS
Clinical Director, MH&AS
RISK ASSESSMENT
Protocol
MENTAL HEALTH & ADDICTION SERVICES
MHAS.A1.44
MENTAL HEALTH & ADDICTION
SERVICES PROTOCOL
REFERENCES
Health and Disability Services Standard NZS 8134:2008
Guidelines for Reducing Violence in Mental Health Services, Ministry of Health,1994
Health and Disability Services (Restraint Minimisation and Safe Practice) Standards NZS
8134.2:2008
Ministry of Health-Guidelines for Clinical Risk Assessment and Management in Mental
Health Services, 1998
Clinical Risk Management Framework, Mental Health Services, July 2003
Assessment & Management of Risk To Others: Guidelines & Development of Training
Toolkit. Mental Health Workforce Development Programme 2006
ASSOCIATED DOCUMENTS
Bay of Plenty District Health Board Mental Health & Addiction Services protocol
MHAS.A1.23 Assessment
Bay of Plenty District Health Board Mental Health & Addiction Services protocol
MHAS.A1.49 Treatment Plan
Bay of Plenty District Health Board Comprehensive Assessment Form
Bay of Plenty District Health Board Risk Assessment Form
Bay of Plenty District Health Board Treatment Plan
Issue Date:
Sep 2015
Page 4 of 4
NOTE: The electronic version of
Review Date:
Sep 2018
Version No: 5
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Business Leader &
assumed to be the current version.
Safety Coordinator, MH&AS
Clinical Director, MH&AS
