Mental Health Care Act, 2002 (Act No. 17 of 2002)

Regulations

General Regulations

Annexures

Form MHCA 13B

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ANNEXURE

FORM MHCA 13B

DEPARTMENT OF HEALTH

PERIODICAL REPORT ON STATE PATIENT

(Section 46(2) of the Act)

Surname of State patient ..........................................................................................................

First name(s) of State patient .....................................................................................................

Date of birth ......................................or estimated age ....................

Gender:

Male

Female

Name of health establishment concerned: .................................................................................

Registration number (if any): ......................................................................................................

Date of first admission of mental health care user under this section: .........................................

Mental health status: (Short statement of the mental health status before and since admission, since the last report, and the present condition, with special reference to any symptom indicating homicidal, suicidal or dangerous tendencies)

Before admission:

...............................................................................................................................................

Since admission / previous report:

...............................................................................................................................................

Present mental status:

...............................................................................................................................................

................................................................................................................................................

Present treatment for example psycho-pharmacological treatment, ECT, occupational therapy or psychotherapy:

.................................................................................................................................................

Present physical condition:

..................................................................................................................................................

Diagnosis at present date:

..................................................................................................................................................

Family contacts:

Personal

Correspondence

Regular

Seldom

Never

In the case of never, what has been done to trace to family?

............................................................................................................................................

.............................................................................................................................................

State patients (section 46 of the Act)

Charge faced:

.............................................................................................................................................

Should the User status remain unchanged?

Yes

Comment:

.............................................................................................................................................

..............................................................................................................................................

If the User be discharged unconditionally ?

Yes

Comment:

............................................................................................................................................

.............................................................................................................................................

Give reasons if the 'present mental status' reflects a normal picture and further confinement is recommended:

............................................................................................................................................

Comment on the merit of granting the User leave of absence:

...........................................................................................................................................

............................................................................................................................................

.............................................................................................................................................

Recommendation on a plan for further care, treatment and rehabilitation (to be completed for any of assisted and involuntary Users and mentally ill prisoners) (Specify treatment programme followed, give details of psychiatric interviews, counselling, group therapy sessions etc., stating clearly the aims of treatment, progress made, assessments done, changes made an patient's reactions to changes):

Please add additional paper as this is extremely important!!

...........................................................................................................................................

............................................................................................................................................

Print initials and surname of assessing practitioner: ..............................

Signature: .............................................................................................

(assessing practitioner)

Date: .......................................

Place: ...................................................

Instructions and remarks

........................................................................................................................................

Signature: .............................................................................................

(Head of health establishment)

Date: .........................................

Place: ....................................................

STATE PATEINTS

'[This part must be completed by head of national department (or designated official)]

Considerations and remarks:

....................................................................................................................................

Recommendations:

(a)	Further care and treatment:

.....................................................................................................................................

(b)	Leave of absence (State patients):

...................................................................................................................................

(c)	Discharge of User:

...................................................................................................................................

Signature: .............................................................................................

(Head of National Department)

Date: ........................................

Place: ..................................................

[Copy to be sent back to the Head of health establishment]

Mental Health Care Act, 2002 (Act No. 17 of 2002)

Regulations

General Regulations

Annexures

Form MHCA 13B

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