LondonDeanery

THE COMPETENCY
CHECKLIST FOR
PSYCHIATRY
FOR CORE TRAINEES

TRAINEE HANDBOOK

This handbook is an overview of the competency checklist for psychiatry, a required

assessment for all new trainees joining core psychiatry training schemes . The handbook
aims to provide you with information about the assessment process and resources to
prepare.
At the back of the handbook is a foldout form that must be completed to evidence you have
completed the assessment.
The Trainee Handbook is available for download on The London Deanery website
http://www.londondeanery.ac.uk/specialty-schools/psychiatry/competency-checklist
Dr Kam Mukherjee
Fellow in Medical Education and Management, School of Psychiatry
Dr Michael Maier
Head of Specialty School of Psychiatry
Dr Bill Travers
Deputy Head of Specialty School of Psychiatry

IN THIS HANDBOOK
OVERVIEW OF
THE CHECKLIST
An overview of what the
checklist is; why it was
developed and what it
entails.

COMPETENCY
CHECKLIST
RESOURCES
Resources to help trainees
prepare for the assessment
are provided.

THE COMPETENCY CHECKLIST

WHAT IS THE CHECKLIST?
WHY WAS IT DEVELOPED?
WHO WILL BE ASSESSED?
HOW CAN I PREPARE?

RESOURCES ON HOW TO
ELICIT A CLINICAL HISTORY IN PSYCHIATRY
PERFORM A MENTAL STATE EXAMINATION
PERFORM A COGNITIVE SCREENING ASSESSMENT
PERFORM A RISK ASSESSMENT IN PSYCHIATRY
MAKE A CASE PRESENTATION AND INITIAL MANAGEMENT PLAN
PERFORM A PHYSICAL EXAMINATION
SAFELY PRESCRIBE INCLUDING RAPID TRANQUILLISATION
DEMONSTRATE COMPETENT WRITTEN COMMUNICATION

SUPPORT AND
SUPERVISION
An overview of the support
and strategies to be made
available to trainees who fail
to demonstrate all the
competences.

THE
COMPETENCY
CHECKLIST
FORM

CONTINUED CLOSE SUPERVSION FOR

TRAINEES WHO DO NOT DEMONSTRATE ALL
THE COMPETENCES
WHAT IS CONTINUED CLOSE SUPERVISION?
HOW LONG WILL IT CONTINUE?
SUPPORT FOR TRAINEES WITH LANGUAGE
AND COMMUNICATION DIFFICULTIES
THE CHECKLIST FORM IS ATTACHED AS A
FOLD-OUT AT THE BACK OF THIS BOOKLET.
EACH CLINICAL SKILL WHEN DEMONSTRATED
COMPETENTLY NEEDS TO BE SIGNED OFF BY AN
ASSESSOR.

THE COMPETENCY
CHECKLIST:
AN OVERVIEW
WHAT IS THE COMPETENCY CHECKLIST?
Commencing training in psychiatry can be daunting for new core trainees. Whilst some core trainees may have
had foundation year experience within psychiatry, many may not have been in a psychiatric setting since
medical school. The competency checklist for psychiatry is a formal assessment process introduced to ensure
that all core trainees have the basic and minimum knowledge, clinical A
skills and communication skills to workB
safely in psychiatry. The competency checklist consists of eight key clinical skills that have been identified as
essential for trainees to be competent in to ensure they can practice psychiatry safely.
The London Deanery requires all new trainees to core psychiatry posts (not higher ST trainees) to be
assessed with this competency checklist. This includes all new CT1 trainees starting core psychiatry training
schemes and all new CT2/3 trainees joining London Deanery core psychiatry training from other deaneries and
all GP trainees in core psychiatry training posts. Completion of the competency checklist is now an ARCP A
requirement for all new trainees to the London Deanery. Please note that failure to complete the competency
checklist can result in the trainee being issued with an unsatisfactory outcome at ARCP.
Within two weeks of starting their first post in core psychiatry, all new trainees should have completed the first
two competences of the checklist (elicit a clinical history and perform a MSE) and then aim to demonstrate all
eight competences by around the end of the first month. This means they have demonstrated and been
signed-off as competent in each of the eight clinical skills on the checklist by a senior doctor in psychiatry,
either consultant or higher speciality trainee (ST4-6, SpR). A staff-grade (SASG) doctor may be an assessor if
this is delegated by your supervisor. In addition, clinical supervisors will also be asked to make a general
assessment of their trainees verbal and written communication and language skills.
Core trainees who can not demonstrate competency 1 (elicit a clinical history) and competency 2 (perform a
D
mental state examination) will need to remain closely supervised in all clinical work and not undertake on-call
duties or outpatient clinics unsupervised until they can demonstrate competency in both these clinical skills.
HOW CAN I PREPARE FOR THE ASSESSMENT?

HOW WILL I BE ASSESSED FOR COMPETENCY?

All of the skills being assessed should be familiar to you

and should have been covered in your medical school
training and some further practiced in your foundation
year training.

Using the checklist form at the back of this booklet,

your first learning objective in the first month of core
psychiatry training should be to be assessed and
signed-off as competent in each of the eight clinical
skills, prioritising demonstration of the first two
competences.

However, you may find it useful to revise the core

knowledge and skills required by reviewing the learning
resources in this handbook prior to starting your post.

You may find this easiest by keeping this booklet on

you and being assessed with real patients in clinical
settings e.g. in clinic or ward round.

Please remember you can re-attempt each clinical skill

multiple times until you are able to demonstrate
competency in that skill. It is therefore a good idea to
keep this booklet on you so you can be opportunistic at
getting each skill signed-off.

If this is not manageable or because of your

supervisors preference, then you may be assessed in
each skill through role-play with an OSCE style
assessment from the trainers toolkit.

WHAT CLINICAL SKILLS WILL BE ASSESSED IN THE

COMPETENCY CHECKLIST?

1. Elicit a Clinical History

Trainee should demonstrate a basic
ability to elicit a psychiatric history,
showing an awareness of the key
areas of importance.

2. Perform a Mental State

Examination
Trainee should demonstrate they
are able to elicit major
psychopathology.

3. Perform Cognitive
Screening Assessment
Trainee should be able to perform
and score a cognitive screening
assessment.

4. Perform a Risk
Assessment

5. Present a Clinical Case

6. Perform Physical
Examination

Trainee must show an awareness of

the importance of historical
identifiers and mental state that
relate to risk.

Trainee to be able to summarise

findings, offer a differential
diagnosis, and propose an initial
safe management plan.

Trainee must demonstrate and

present a reliable and appropriate
physical examination.

PLUS Global impression of

trainees verbal and
written language and
communication skills.

7. Prescribe safely in
Psychiatry
Trainee to demonstrate they can
prescribe accurately and safely and
be able to prescribe rapid
tranquillisation according to local
guidelines.

8. Write clinical letter or

report
Trainee to demonstrate basic
competence in language and
communication and accurately
convey relevant clinical information
with clear plan.

THE COMPETENCY
CHECKLIST:
RESOURCES TO PREPARE

Foremost, do not worry about this assessment. All of the knowledge and skills being assessed
should have been covered in your medical school training in psychiatry and foundation year
training. You may just need to revise and brush up on some areas prior to starting your post.

This section of the handbook will go through each competency that will be assessed with tips
and resources on how to prepare.

The resources provided here only briefly cover the key topics that are being assessed, so
further reading and supervision is advised. Suggested further reading is given at the end of the
book.

COMPETENCY 1:

ELICIT A CLINICAL HISTORY FOR

A COMMON PSYCHIATRIC
DISORDER
This assessment will look at your ability to gather relevant information from a patient presenting with a
common psychiatric disorder. You will not be expected to demonstrate a sophisticated clinical interview but
be able to sensibly collect information on the relevant areas to allow for an accurate clinical picture of the
patients presentation.
You will be asked to take a history from a patient. You may be assessed by interviewing a patient or
alternatively you may be assessed by role-play with your trainer.

You may want to include questioning in the following main areas:

Name, age, occupation

The presenting complaint/reason for referral
The history of the presenting complaint
Family history
Personal and developmental history including social history
Psychiatric history
Medical history
Drug and alcohol history
Forensic history
Brief assessment of personality

Dont forget to:

Introduce yourself and explain the purpose of the interview

Bear in mind partners, carers and dependents of the patient
Have empathy with the patient

Resources:
A suggested scheme for taking a comprehensive psychiatric history is given to highlight key important areas
of questioning to consider.
You will not need to ask all the questions covered but should be able to demonstrate that you have covered
the main relevant areas.

TAKING A PSYCHIATRIC HISTORY

This section only contains some brief notes that may help you
take a psychiatric history. To develop your history taking skills
beyond competency will require further self-directed learning,
practice and supervision.

Remember a full psychiatric assessment requires a full history and a full mental state examination. Although
some of the questions may overlap, generally the history aims to find out what has been going on recently
(leading up to this point), while the mental state examination aims to assess the patients mood, thoughts etc.
at the time of assessment. When eliciting a psychiatric history, try and understand the narrative of the patient
rather than compartmentalizing the interview.
TO BEGIN ASSESSEMENT INCLUDE

1. REFERRAL AND
INFORMANTS

Prior to starting the interview,

consider the following:

The patients details and demographics.

When and where your patient is being seen? (e.g. on the ward,
in A & E or in Section 136 suite)
Legal status of patient: voluntary or detained.
Why are they being seen?
Who was history taken from: patient or carer?

2. INTRODUCTION
As with any clinical
assessment you must start
with an introduction. You may
want to include the following:

V3. PRESENTING
COMPLAINT

Who you are and the purpose of the interview

How long you have to interview the patient.
Consent, confidentiality and permission to take notes.
Ask about demographics, name, date of birth, occupation and
marital status.
Other information regarding ethnicity, culture and language.

Ask the patient to tell you in their own words, what the chief
complaints are by the client as you would in any clinical
history before commencing the history of presenting
complaint.

4. HISTORY OF
PRESENTING COMPLAINT

You now want to find out

more about the symptoms
including:

Duration and mode of onset.

Time relations between symptoms and any physical disorder
or psychological or social problems.
Nature and duration of any difficulty.
Any treatment received.

You may find it useful to use SOCRATES - The mnemonic for taking
a history of a pain: Site (where/when the problems cause most
difficulty), Onset (when it started) Character, Radiation (e.g. what
other areas of life are impacted), Alleviating factors, Time course (e.g.
pervasive, episodic), Exacerbating and precipitating factors, Severity.

Use open and closed questions to clarify further then vary depending on the specific problem
that the patient has presented with:
a. DEPRESSION
Treat feelings of low mood in the same way you would treat pain, find out everything about the depression
before moving on to ask about other features/associated symptoms.
How has mood been? How long has mood been low for? Is mood always low? Is it worse in the mornings?
(Diurnal variation in mood where mood is worse in the morning is a sign of more severe depression). Can you
do anything to lift your mood? Do you ever look forward to anything? Are you ever tearful? Do you ever feel
guilty, worthless or hopeless? Do you ever self-harm? Have you ever thought of ending it all? If yes, have you
made plans to end it all (or kill yourself)?
Ask about associated symptoms: Is the patient experiencing other physical symptoms? Is appetite
reduced? Any weight loss? Lack of motivation? Any sleep changes (trouble getting to sleep can be a sign of
depression, or is there early morning waking - a sign of more severe depression)? Any other physical
symptoms: lethargy, aches and pains? Has sex drive/libido changed? Has concentration waned? Have these
symptoms caused problems at work or at home?
If your patient is presenting with self-harm e.g. an overdose, be sure to get a full history of the selfharm (see risk assessment: competency 4)
b. PSYCHOSIS:
It may be difficult to work out what symptoms a patient with psychosis is experiencing as they are unlikely to
tell you they are suffering from delusions etc. Some questions you could ask include:

Have you had any unusual thoughts recently or have others commented on you being
strange/different?
Do you feel like any individual or group are against you?
Are your thoughts in your head your own? Are the thoughts clear?
Have people been interfering with your thoughts: putting thoughts into your head (thought insertion) or
are your thoughts being withdrawn (thought deletion) or broadcast.
Do you ever see or hear things that other people seem unable to see or hear? (e.g. auditory
hallucinations). If yes, are the voices talking about you (third person) or to you (second person), are they
commenting on what you are doing (running commentary) or are they telling you to do certain things
(command), if so what? Do the voices ever tell you to do things you dont want do?
Do you believe the voices and do you do what they tell you to do?
Try to get an idea of how long these problems have been going on and how they have changed over
time and what the patients understanding of the experience is.
9

When screening for schizophrenia ask about Schneider's first-rank symptoms of schizophrenia are
symptoms. These symptoms if present are strongly suggestive of schizophrenia. These include:

10

Auditory hallucinations:
hearing thoughts spoken aloud
hearing voices referring to himself / herself, made in the third person
auditory hallucinations in the form of a commentary
Thought withdrawal, insertion and interruption
Thought broadcasting
Somatic hallucinations
Delusional perception
Feelings or actions experienced as made or influenced by external agents

c. ANXIETY
Depending on the presenting complaint you may want to ask about the following:

Generalised anxiety; general feelings of anxiousness, feeling on edge, worry, irritable, unable to relax.
Panic attacks; hyperventilation, breathlessness, chest pain/ palpitations, sweating, tremor. Ask how
long do attacks last and what brings them on.
Phobias; any fears that may be considered to be excessive.
Obsessions and Compulsions

IMPORTANT TO ASK WITH ALL PATIENTS:

What does patient think the cause is?

Are there any recent events that have precipitated the presenting complaint? These events may be
negative (separation, death in family) or may appear positive (promotion at work but has led to
increased stress).
What is the present social situation and what is the impact of the illness on their life?

5. FAMILY MEDICAL AND

PSYCHIATRIC HISTORY
You may want to draw a
genogram.

Is there a family history of psychiatric or relevant medical illnesses?

You may wish to specifically enquire about neurological disorders, dementia, suicides, criminal
behaviour or alcoholism?
What is the family structure and relationships? Identify carers and dependents also.
10

6. PERSONAL HISTORY

Here you want to collect

information about the patient
from birth to present day. Some
areas that you may want to
include are:

7. PSYCHIATRIC HISTORY

You may want to include the

following:

As with any clinical history

take a full medical and
surgical history.

You may want to ask about

all current medications,
prescribed, over the counter
and street drugs and always

11

All psychiatric history including past contact with psychiatric or

mental health services.
Dates, diagnosis, treatment, duration, legal status of any admissions
Always ask about a history of self-harm or suicide attempts.
What has triggered problems/relapses in the past?

Due to related psychiatric co-morbidity you may want to specifically

ask about:

8. MEDICAL HISTORY

9. MEDICATION/
TREATMENT HISTORY

Pregnancy and birth of the patient

Developmental history e.g. milestones and delay in motor, verbal,
toileting and social domains
Childhood trauma e.g. separation from parents, abuse
Schooling and further training e.g. relationships at school, bullying
(either victim or perpetrator), academic achievement
Occupational history
Sexual History including menstrual history
Relationship history and children
Current social circumstances: accommodation, benefits, finances

Head injury
Meningitis /encephalitis
Epilepsy
Developmental problems

It may be relevant to enquire about:

Treatments that have been already tried/used in the past and did they
work?
Does the patient have any problems with any medications, do any
medications have any side effects, does patient find it easy to comply
with treatment, what are the patients thoughts towards treatments
e.g. do they feel they need medication?

And finally with the psychiatric history dont forget to include:

10. DRUG AND ALCOHOL
HISTORY
How much? How often? What
types of drink/drugs? Any
withdrawal symptoms?
Remember the mnemonic
CAGE and screen for
dependency?

11. FORENSIC HISTORY

12. PERSONALITY

You may want to ask about

arrests, convictions and
imprisonments.

You may want to make an

assessment of personality
this may include questions
on relationships, friendships,
leisure activities, prevailing
mood, character, attitudes
and habits including drugs
and alcohol.

The nature of offences and

their dangerousness should
be clarified.

11

12

COMPETENCY 2:
PERFORM A MENTAL STATE
EXAMINATION FOR A COMMON
PSYCHIATRIC DISORDER
This assessment will look at your ability:

To demonstrate sufficient knowledge of the components of the mental state examination (MSE).
To clearly and coherently observe/enquire about common signs and symptoms of psychopathology.
This will also require a basic understanding of the common signs and symptoms of mental
disorders and skills in descriptive psychopathology.
CHECKLIST FOR MSE

1. Appearance and Behaviour

Appearance e.g. grooming, hygiene, clothing, physical health
Eye contact and Facial expression
Attitude to situation and examiner e.g. hostile, withdrawn, seductive
Motor behaviour e.g. slowed down, restless, tremors, posture
Any bizarre behaviour e.g. appearing to respond to hallucinations
2. Speech
Rate e.g. slow, pressured (very rapid), able to interrupt; tone e.g. monotonous; volume e.g. loud, quiet, slurred; quantity
of information e.g. restricted amount of spontaneous speech; neologisms, echolalia, perseveration, dysathria
3. Mood and affect
Mood e.g. depressed, euphoric, suspicious, irritable, anxious
Lability; Affect e.g. restricted, flattened (absence of emotional expression) and incongruity
4. Form of thought
Amount of thought and rate of production e.g. hesitant thinking, vague, flight of ideas
Continuity of ideas - refers to logical order of the flow of ideas
Disturbance in language or meaning
5. Content of thought
Delusions and overvalued ideas
Suicidal thoughts, plans or intent
Other e.g. obsessions, compulsions, hypochondriacal preoccupations
6. Perception
Hallucinations relating to sounds heard, visions, smells, tastes, tactile or somatic sensations. Note in particular any
command hallucinations. Does the patient think that he or she may act upon these?
Other perceptual disturbances
7. Cognition
Level of consciousness Memory: immediate, recent, remote
Orientation: time, place, person
Concentration: ask the individual to subtract serial 7s from 100
Abstract thinking
8. Insight
Extent of individual's awareness of problem. Compliance with treatment.
12

13

MENTAL STATE EXAMINATION

Below is further information on the signs or symptoms you may
observe, consider or enquire about as you perform a BASIC mental
state examination.
Using the references listed in the suggested reading or with your
own favoured textbook in general adult psychiatry, take time to
look up and understand all the underlined terms italics.

1. APPEARANCE AND
BEHAVIOUR
You can obtain a great deal of
information about a patient by
careful observation alone:

With careful observation alone:

Assess the patients level of self-care (note any self neglect

which may be associated with depression and dementia).

Note any weight loss or signs of physical illness e.g. as may

be seen in depression, eating disorders.

Note any oddity of dress (e.g. occasionally manic patients may wear very bright or incongruous
clothes; hats or sunglasses may be worn for reasons relating to patients elation or delusions).

Assess eye contact (may be reduced in depression; avoidant in a suspicious patient or staring with
Parkinsonism and following use of some drugs.

Note facial appearance (may reflect mood as depressed, elated, anxious or angry). Also note if the
patient shows little variation in facial expression (may be seen in depression and Parkinsons).

Describe carefully any unusual behaviours that you observe such as appearing to respond to auditory
hallucinations.

Note posture and movement, this will include psychomotor agitation or retardation. Abnormal motor
movements may be observed:

Tardive dyskinesia (may be secondary to psychotropic medication)

Tremors and tics
Stereotypies and Mannerisms
Stupor and signs of catatonia

2. SPEECH
Note its volume, rate, quantity
and flow.

Assessing speech also involves assessing the type and quality of

speech and not the thought content. Note its volume, rate, quantity
and flow.
Also make a note of any articulation difficulties (Dysarthria). Some
patients may use new words constructed by them or attach
personal meaning to existing words (Neologism). Echolalia
(repeating same words phrases as examiner) should also be noted.
13

3. MOOD

14

To assess for depression you may want to enquire about

sadness and tearfulness. There may also be negative
thoughts about the present and hopelessness about the
future. Key indicators of depression are: loss of appetite,
weight loss, poor sleep especially early morning wakening
and diurnal variation in mood where mood is worse in the
morning. It is important to enquire about any thoughts of
self-harm and suicide.

To assess mood try to

enquire about the patients
subjective experience (How
would you describe your
mood?)

To assess for anxiety you may want to ask how the patient feels when anxious. Ask about
palpitations, dry mouth, sweating, trembling, feeling of losing control or fainting.

To assess mania, you may want to ask, How are your spirits, unusually good? and enquire about
irritability. Also enquire about levels of energy, excessive spending and any other unusual excessive
activity.

As well as the patients own description of their mood; note your own assessment of their mood. Their affect
is their overall communication of mood to you. Do they seem to have a mood that varies excessively during
interview (labile mood) or have a flattened expression of emotion (termed a blunted or flattened affect). Note
any incongruity of mood.

4. THOUGHTS
You need to assess the stream
and form of thought and elicit
any abnormal content of
thought.

Stream of thought disorders may include pressure of thought

(e.g. mania), poverty of thought (e.g. depression) or thought
block (e.g. schizophrenia).

Form of thought disorders may include flight of ideas

(characteristic of mania), loosening of association (seen in
psychosis) and knights move thinking.

Content of thought may include delusions, overvalued ideas,

obsessions and compulsions.

You are advised to undertake further reading on the following. Properly understanding the terms will
help you to enquire about them correctly and later interpret them: (see reading list at back)

Definitions of Delusions and Overvalued ideas

Types of delusion (e.g. primary, secondary, delusional perception)

Common themes of delusion (e.g. Persecution, Reference, Grandiosity, Nihilistic)

Delusions concerning control (Passivity phenomena) and thought possession (e.g. thought insertion,
withdrawal and broadcasting)

Obsessional phenomena and compulsive rituals.

Depersonalisation and derealisation

Schneiders First Rank Symptoms of Schizophrenia

14

This can be introduced by asking about any unusual experiences

followed by enquiry about hearing sounds or voices when there is
no one around.

5. PERCEPTION
It is important to sensitively
enquire about abnormalities
of perception this includes
hallucinations.

Abnormalities of perception can occur in all sensory

modalities (though auditory hallucinations are the most
common) so enquire about all modalities.

It is important to distinguish if the abnormality of perception

is a true hallucination or a pseudohallucination.

15

You are advised to undertake further reading to ensure you know how to do the following:

How to distinguish hallucinations from illusions and pseudo hallucinations.

How to determine if auditory hallucinations are 3rd Person, 2nd Person (including command
hallucinations), thought echo or thought commentary.

Know the relevance of hallucinations to psychopathology (e.g. 3rd person auditory hallucinations
should make you consider schizophrenia; visual hallucinations occur in 10% of patients with
schizophrenia; fully formed visual hallucinations are not due to organic brain disease, which are usually
accompanied by unformed visual disturbances and abnormal sensory stimuli).

Know the relevance of hallucinations to risk (e.g. command hallucinations to harm self or others
indicate a high risk patient).

6.

COGNITIVE FUNCTION

Make sure your assessment includes:

Consider using a cognitive

screening tool such as MMSE
or SMMSE.

Level of consciousness
Memory: immediate, recent, remote
Orientation: time, place, person
Concentration: ask the individual to subtract serial 7s from 100
or 3s from 20.n

Abstract thinking

7. INSIGHT

At a very minimum, enquire and make comment on:

Assessing insight is important

to ascertain the severity of
illness, future management
and risk. It is not enough to
merely state insight present
or no insight.

The patients explanation of the illness/presentation.

Do they recognise that they have a mental illness and are they
able to re-label unusual events e.g. hearing voices as
pathological?

Are they able to recognise aetiological factors e.g. stressful life

events as having played a part?

What are their views on admission, treatment, and medication?

15

COMPETENCY 3:

16

PERFORM A COGNITIVE
SCREENING ASSESSMENT
This assessment will look at your ability:
To perform a brief but comprehensive cognitive screening test such as the Mini-Mental State Examination
(MMSE) or Standardised Mini-Mental State Examination (SMMSE) either to be demonstrated in role-play
with your supervisor or in interview with a real patient. There are two parts to the assessment:

Firstly, you must demonstrate the verbal communication skills to complete task. This means you
should be able to make all instructions readily understandable to the patient. It is worth practicing
with someone else how you phrase each instruction and seeing how well you are understood.

Secondly, you must understand the scoring of any screening tool you use and be able to calculate
the correct score for the patient. To demonstrate competency, your score should be within 1 point
of your trainers score.

Dont forget to introduce yourself and state the purpose of the test you are doing.
An Abbreviated Mental Test (AMT) is not sufficient to demonstrate this competency.
Remember that the SMMSE/MMSE do not diagnose dementia. They are screening tools for cognitive
impairment. The scores can be suggestive of the degree of impairment.
Both the MMSE and the SSMSE can be used clinically but the forms not photocopied without
permission. Sample copies only of the MMSE and SMMSE have been provided but cannot be should
not be modified or reproduced due to copyright.
To order or obtain additional information on the MMSE contact: Psychological Assessment Resources, Inc.
(PAR) 16204 N. Florida Avenue Lutz, Florida 33549
To order or obtain additional information on the SMMSE please call: (905) 628-0354 or e-mail at:
[email protected]

16

17

A Sample Mini-Mental State Examination (MMSE)

Maximum
Score

Score
ORIENTATION

What is the (year), (season), (date), (day), (month)

Where are we (state), (county), (town or city), (hospital), (floor)

REGISTRATION

Name 3 common objects, (e.g. apple, table, penny).

Take 1 second to say each. Then ask the patient to repeat all 3 after
you have said them. Give 1 point for each correct answer. Then
repeat them until he/she learns all 3. Count trials and record.
Trials:
ATTENTION AND CALCULATION

Spell world backwards. The score is the number of letters in the

correct order ( D__ L__ R__ O__ W__ )
RECALL

Ask for the 3 objects repeated above. Give 1 point for each correct
answer. [Note: recall cannot be tested if all 3 objects were not
remembered during registration.]
LANGUAGE

Name a pencil and watch (2 points)

Repeat the following No, ifs, ands, or buts

(1 point)

Follow a 3-stage command:

Take a paper in your right hand,
Fold it in half, and
Put it on the floor

(3 points)

Read and obey the following:

1
1
1

(
(
(

)
)
)

Close your eyes

(1 point)
Write a sentence
(1 point)
Copy a diagram of intersecting pentagons (1 point)

17

18

SAMPLE SMMSE FORM

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18

COMPETENCY 4:

19

PERFORM A RISK ASSESSMENT

Risk assessment is an essential component of every psychiatric assessment. It is imperative that you ask
specifically about each of the key domains of risk listed in the box below.
Your trust is likely to have both a risk assessment protocol and mandatory forms that need to be completed
on each client. Please take some time to familiarise yourself with both.
In this section, we will only briefly cover the key domains of risk that you need to enquire about and then look
a little more closely at assessing self harm as this is a common clinical presentation. Trainees are advised to
undertake further reading and request supervision on this topic.

Risk Assessment Key Domains:

To ensure a competent risk assessment, in addition to or incorporated within your history and MSE you must
enquire about risk in the following categories
(Examples of each category are given under each heading):
Self Harm
(e.g. Suicidal Ideas / Plans / Attempts; Self-harm / Injury e.g. cutting, poisoning, burning; Substance Misuse)
Self Neglect
(e.g. Poor nutrition and personal hygiene; unable to cook / feed self; unable to wash / dress self; poor budgeting, not
taking medication)
Harm to others (dangerousness)
(e.g. Aggression / violence / abuse to others and animals; including sexual/domestic/other abuse (including touching
/exposure); command hallucinations: arrests/conviction for violent or sexual offence; preoccupation/obsession with
weapons; arson / fire setting; hostage taking; violence/aggression/abuse to staff; threats to kill; stalking / harassment;
risk to children; risk to vulnerable adults; exploitation of others (financial/emotional);risk to escape/abscond)
Harm from others (vulnerability)
(e.g. neglect by carers; sexual exploitation; bullying; risk of unlawful restrictions e.g. locks on doors, physical restraints;
risk of physical harm; and risk caused by medical/services/treatment)
Risk to children
Please consider: Is the patient in contact with any children, related or unrelated? If yes, consider if there are any risks to
children (e.g. neglect, abuse).
There are some other areas of risk you may also want to consider: (Accidents; driving; road safety; incidents
involving police; damage to property; theft; phone calls; correspondence; disengagement from mental health services
pregnancy etc)
Assess for protective factors
(e.g. religion, family, previous good response to treatment)
19

20

ASSESSING RISK
Below is some further information on assessing patients who present with risk
of suicide and self-harm.
Remember risk assessment must include risk to others, , risk from others,
vulnerability as well as risk to self (not just self-harm but also neglect, noncompliance and substance misuse).
A risk assessment is only useful if it leads to a carefully constructed
management plan to address all risks identified.
Risk assessment to predict suicide by any clinician is difficult as there are multiple variables to take into
account. Published research has however identified some risk factors, which should alert all clinicians to an
increased risk of an adverse outcome. NOTE: A risk assessment is only useful if it leads to a carefully
constructed management plan to address all risks.

SUICIDE RISK FACTORS

It is important to recognise
some important risk factors
for suicide. These include:

ASSESSING A PATIENT
WHO HAS SELF HARMED

Male gender and increasing age

Single, widowed, divorced
Social isolation
Suicidal intent or ideation
Pervasive feelings of hopelessness
Recent adverse life events
History of previous attempted self-harm
Depressive illness and other psychiatric disorders (noncompliance)
Presence of physical illness and chronic pain
History of substance misuse
Recent discharge from hospital

As a core trainee, you may be asked frequently to assess patients

who have harmed themselves and to make a judgment on the level of
risk that they pose to themselves. To determine this, you will want to
consider the details of the episode of self-harm including the
premeditation and intent. You may find it useful to use the questions
in either the Becks or Pierce suicide intent rating scales.
A sample of the Pierce suicide intent scale has been given on the
next page.

DO NOT FORGET TO ASK ABOUT:

Trigger for episode of self harm

Ongoing thoughts of self harm, any suicide intent or plans
Psychiatric history
History of self harm
Alcohol/Drug misuse (also in relation to self harm episode)
Protective factors and support network

A FULL HISTORY AND MSE SHOULD IDENTIFY CO-MORBID DEPRESSION OR PSYCHOSIS

20

21
Pierce Suicide Intent Scale To be completed after suicide attempt
Pierce, D.W. (1977) British Journal of Psychiatry, 130, 377-385

Isolation

Timing

Precautions against rescue

Acting to gain help

Final acts in anticipation

Suicide note

Lethality

Stated intent

Circumstances
0
1

10

Reaction to act

11

Predictable outcome

12

Death without medical treatment

No-one nearby

Timed so intervention probable

1
2

Intervention unlikely
Intervention highly unlikely

0
1
2

None
Passive (e.g. alone in room, door
unlocked)
Active precautions

0
1

Notifies helper of attempt

Contacts helper, doesnt tell

2
0
1

No contact with helper

None
Partial preparation

2
0
1

Definite plans (e.g. will, insurance,

gifts)
None
Note torn up

Presence of note

Self-report
0
1

Premeditation

Someone present
Someone nearby or on telephone

Thought would not kill

Unsure if lethal action

Believed would kill

0
1

Did not want to die

Unsure

Wanted to die

0
1
2

Impulsive
Considered less than 1 hour
Considered less than 1 day

Considered more than 1 day

0
1
2

Glad recovered
Uncertain
Sorry he/she failed

0
1

Survival certain
Death unlikely

2
0
1

Death likely or certain

No
Uncertain

Yes

Risk

Items (1 + 2 + 3 + 4 + 5 + 6) = circumstances score = __________

Items (7 + 8 + 9 + 10) = self-report score
= __________
Items (11 + 12) = Medical risk score
= __________
Total score 0 3 = Low Intent; 4 10 = Medium Intent; More than 10 = High Intent

21

COMPETENCY 5:

22

PRESENT A CASE WITH BASIC

MANAGEMENT PLAN
This is an assessment task to test your ability to present a psychiatric assessment and BASIC plan (e.g.
presenting to a consultant on ward round or over the phone to your registrar when on call or handing over to
a colleague).
You need to include the relevant components of the history, mental state examination and any risk factors.
You may want to include any positive findings on physical examination.
You may want to include a brief formulation looking at aetiological (The 4 Ps: predisposing, precipitating,
perpetuating and protective) factors (using a bio-psycho-social model).
You should include a differential diagnosis and then state your preferred diagnosis
You should offer a BASIC management plan as you are at the start of your training you only need to
demonstrate you can make a safe plan for a patient. At this juncture we are not expecting you to make wellconstructed long-term plans for patients but to offer a sensible short-term plan that addresses cases you may
have to manage out-of-hours e.g. offer a short term plan for a suicidal patient or a plan for a psychotic
patient who presents in A and E and who does not want to be admitted.

MAKING A MANAGEMENT PLAN

When making a management plan you may want to consider:

Is a corroborative history needed/notes needed?

Are further investigations needed? e.g. Alcometer, urine drug screen, blood tests

Are they medically cleared? Have organic causes been excluded?

Are they safe to be discharged or should admission be considered?

If they are discharged what is the follow up plan? When? Where? By who?

If considering admission consider capacity, mental health legislation

If admitted, what is plan on ward? Think level of observation, any medication they may need,
any children/pets to consider

Never forget to ask yourself - Do I need senior support?

22

COMPETENCY 6:

23

PERFORM PHYSICAL
EXAMINATION

In recent years concerns have been raised about missed unmet physical health care in mental health
patients. Some trainees have shown difficulties in performing physical examination in membership
CASC examinations. It is important that any difficulties are identified early by this assessment and that
trainees continue to retain skills in physical healthcare and examination whilst practicing as
psychiatrists.
Physical examination is an important part of a psychiatric assessment. It allows doctors to exclude
organic causes; identify and manage any co-morbid physical illness and monitor any side-effects from
psychotropic medication. All newly admitted patients to a mental health unit should have a full physical
examination, which must be documented in the notes.
To demonstrate this competency you will be asked to perform a physical examination: this should be a
systematic physical examination as would be appropriate for any new inpatient admission to a hospital.
You should then be able to give a clear summary of the physical examination and may include any other
information needed to complete assessment e.g. temperature, weight.
To demonstrate this competency to perform a physical examination you need to be able to:

Clearly explain to patient what you are going to do and give clear and readily understandable
instructions when appropriate.

At a very minimum this should include:

o
o
o
o
o
o

General observation of patient including end of the bed, examination of hands and face
Be able to measure pulse, blood pressure and respiratory rate
Appropriate examination of the cardiac and respiratory systems
Appropriate examination of abdomen
Examination of cranial nerves and peripheral nervous system
You may be asked to do fundoscopy

23

COMPETENCY 7:

24

PRESCRIBE MEDICATION SAFELY

INCLUDING RAPID
TRANQUILLISATION
To assess this clinical skill you will be asked to fill in a drug chart for a patient. Trust audits highlight that a
significant number of patient prescription charts have been filled in incorrectly. In particular the prescribing of
tranquillisation of disturbed or agitated patients has been identified as an area of concern.
You will be asked to write up rapid tranquillisation medication on the as required (PRN) on one of your
own trust prescription/medication charts.
You may also be asked to prescribe some further medication (you will be given the name, dose and
frequency) and need to complete the chart accordingly.
THIS COMPETENCY ASSESSMENT MAY BE SIGNED OFF BY A WARD OR TRUST PHARMACIST, YOU
CAN SCHEDULE THIS YOURSELF OR IT MAY BE SCHEDULED INTO PART OF A PHARMACY TRUST
INDUCTION.

THIS CLINICAL SKILL REQUIRES ALL THE PRINCIPLES OF GOOD PRESCRIBING

IN ANY CLINICAL SPECIALTY:
1. Have clear and legible handwriting. Upper case preferable. Most trusts require the use of black ink.
2. Always check personal details
3. Fill in allergy box even if to state there are no allergies
4. Prescribe the drugs with the generic name and dosage (both number and units)
5. All medications prescribed should be signed and dated
6. With PRN medication ensure frequency, reason for use and maximum in 24 hours are clearly stated
You also need to be aware of your trusts rapid tranquillisation protocols and algorithm and prescribe
accordingly. This may be covered in your Trust Induction but it may be sensible to speak to your
trainer or ward pharmacist about this at the start of the post prior to assessment.
Note: for Children and Adolescents and also with the elderly, the medications and doses use vary. Your trust
can provide you with their guidance on this.

24

We have below and overleaf provided the NICE guidelines algorithm but we also suggest you familiarise
yourself with the following NICE guidelines documents available electronically:

25

1. Violence: The short-term management of disturbed/violent behaviour in psychiatric in-patient

settings and emergency departments:
http://www.nice.org.uk/nicemedia/live/10964/29716/29716.pdf
2. Summary of Product Characteristics:
http://www.nice.org.uk/nicemedia/live/10964/29718/29718.pdf
12

NICE Guideline: quick reference guide Violence

Rapid tranquillisation (RT) algorithm

This algorithm should be read in conjunction with the recommendations in the guideline
and the Summary of Product Characteristics (SPC) chart for rapid tranquillisation, available at www.nice.org.uk/CG025
See also page 15 of this quick reference guide

All staff involved in RT should be trained according to the

recommendations set out on pages 2122
Continue to use de-escalation techniques throughout

Potential risks

Caution

Consult

Preferred method
of drug
administration
(1 = preferred D )

Over-sedation causing loss of consciousness

Over-sedation causing loss of alertness
Loss of airway
Cardiovascular and respiratory collapse
Interaction with medication (prescribed or
illicit)
Damage to the therapeutic relationship
Underlying coincidental physical
disorders D

Take extra care in presence of:

congenital prolonged QTc syndromes
medications that lengthen QTc intervals
directly or indirectly
hypo/hyperthermia, stress/extreme
emotions, extreme physical exertion D

Advance directives if available D

1 Oral
Allow sufficient
time for clinical
response between
doses B

2 Intramuscular (i/m)
Allow sufficient time
for clinical response
between doses B

Service users should be able to respond to communication

throughout
D
Prescribe oral and i/m doses separately
D
Dont use o/i/m abbreviation
D
Dont use two drugs of same class for RT
D
Dont mix medications in same syringe D(GPP)

Prescribers and those who administer medicines should be familiar with:

the properties of benzodiazepines; flumazenil; antipsychotics; antimuscarinics and antihistamines
risks (including cardio-respiratory effects, particularly if with high arousal, possible drug misuse,
dehydration or physical illness)
the need to titrate doses to effect
D
Prescriber and medication administrator should pay attention to:
the total dose prescribed
arrangements for review
consent, British National Formulary (BNF) and SPC requirements, physical and mental status
D

There are specific risks with different classes of medication. Risks may be compounded if used in combination.
Benzodiazepines: loss of consciousness; respiratory depression or arrest; cardiovascular collapse when
receiving both clozapine and benzodiazepines
Antipsychotics: loss of consciousness, cardiovascular/respiratory complications and collapse; seizures; akathisia;
dystonia; dyskinesia; neuroleptic malignant syndrome; excessive sedation
Antihistamines: excessive sedation; painful injection; additional antimuscarinic effects D(GPP)

Consider all
medication as part
of RT (including
pro re nata from
agreed RT protocol
or advance
directive) D

Non-psychotic
context

Consider oral lorazepam B

Psychotic
context

Consider oral lorazepam + oral

antipsychotic D

Non-psychotic
context

Oral therapy is:

refused or has failed
not indicated by previous clinical response
not a proportionate response

Consider i/m lorazepam

(if oral route inappropriate) B

Algorithm continued on next page

25

26

Transfer to oral
route at earliest
opportunity D

Psychotic
context

3 Intravenous (i/v)
(Exceptional
circumstances
only)

After RT

NICE Guideline: quick reference guide Violence

Monitor vital signs

D
Record blood pressure, pulse,
temperature, respiratory rate and
hydration at intervals agreed by
multidisciplinary team until service user
active again
D
Pulse oximeters should be available
D

Drugs NOT recommended for RT

Immediate
tranquillisation
essential

Oral or i/m chlorpromazine

C
i/m diazepam
C
Thioridizine
C
i/m depot antipsychotics
D
Olanzapine (dementia-related disturbance)
C
Risperidone (dementia-related disturbance)
C

Oral therapy is:

refused or has
failed
not indicated
by previous
clinical
response
not a
proportionate
response

Consider i/m lorazepam + i/m haloperidol B

Consider i/v
benzodiazepines
or haloperidol
D

Decision to
use not to be
made by
junior staff in
isolation D
Specify and
record
circumstances
for use D

olanzapine*

May also consider i/m

moderate disturbance B

for

! Dont give i/m lorazepam within

1 hour of i/m olanzapine. Use oral lorazepam
with caution B
* The

manufacturer has issued a warning that use

outside of the details contained within the SPC may
increase the risk of fatality

Intensive and frequent monitoring by

trained staff required if:
service user is/appears sedated/asleep
i/v administration used
BNF limit or SPC exceeded
in high-risk situations
illicit substances/alcohol ingested
presence of relevant medical
disorder/taking prescribed medication
Pay particular attention to respiratory
effort, airway and level of consciousness
Record in care plan D

Zuclopenthixol acetate**
Not recommended for RT due to long onset and duration of action, but
may be considered as an option when:
service user will be disturbed/violent over extended time period
past history of good/timely response
past history of repeated parenteral administration
cited in an advance directive
Never administer to those without previous antipsychotic exposure
Consult BNF and manufacturers SPC regarding its use B
** Zuclopenthixol acetate is commonly known as acuphase by staff and service users

When using haloperidol:

procyclidine or
benzatropine should be
immediately available
to reduce risk of
dystonia or other
extrapyramidal
side-effects D
Give procyclidine or
benzatropine i/m or i/v
as manufacturers
instruction D

Be aware of symptoms of:

respiratory depression
dystonia
cardiovascular compromise
D
Crash bag must be available within 3 mins
D
Staff must be trained to Immediate Life Support
(ILS)
D
Never leave service user unattended
D

If verbal
responsiveness is lost:
use level of care
as for general
anaesthesia D

Post-incident
review within
72 hours D(GPP)

When transferring a service user between units,

the following should also be sent:
a full medication history (including the service
users response to medications) and any
adverse effects
an advance directive
the service users account of their experience
(where possible)
On discharge, file all such information in
their healthcare record to be reviewed
regularly. D(GPP)

13

Interventions for the management of disturbed/violent behaviour

26

COMPETENCY 8:

27

WRITTEN COMMUNICATION
ASSESSMENT
Assessment of your written communication will require you to bring a piece of written communication
that you have written, typed or dictated yourself.

Examples of written communication you can bring for assessment include

A GP/clinic letter
An admission assessment
An assessment/discharge letter or summary
A referral letter
A report

If you have not yet written any of the above, your trainer may ask you to draft a letter from one of the
scenarios you were assessed in earlier (e.g. competencies 1,2 or 4 and 5).
To ensure competence in this clinical skill you must:

Be able to produce evidence that you have the language, grammar and writing skills to produce
accurate and understandable letters to other health professionals.

Be able to accurately summarise the relevant aspects of the history and mental state examination in
writing, using correct terminology and phenomenology where appropriate.

You may bring a letter that you have dictated but has been typed by administrative staff. However, do
check for typos and mistakes, as you will be responsible for those errors.

27

CONTINUED CLOSE
SUPERVISION

28

New starters to psychiatry and close supervision

All new trainees are routinely supervised closely and supported during the first two weeks of their new post.
This two-week period helps you find your feet in the field of mental health care, which may be very new and
different to your previous foundation posts. In this two week period you should not be working outpatient
clinics or doing on call work without being closely supervised or doing joint assessments.

Continued close supervision

Trainees who demonstrate all eight competencies have demonstrated they have the skills and
knowledge to work independently with regular supervision for a CT1 trainee.

If you are unable to achieve competency 1 and 2 (elicit a clinical history and perform a MSE), you
will have to have continued close supervision in all areas of your clinical work.
Until you demonstrate that you can take a reliable history and perform a competent MSE, you should
not be taking part in outpatient clinics or on-call work without close supervision in all your cases.

If you have achieved competencies 1 and 2 but have not demonstrated one or more of
competencies 3 to 8, you will only be supervised closely in those domains relevant to the unachieved
competencies.

This level of continued close supervision has two crucial roles:

Firstly, patient safety and quality of care is a priority. Close supervision ensures that until a trainee has the
necessary skills to work independently, trainers need to ensure safe, good quality care and service provision.
Secondly, it is crucial for trainees to have their learning needs identified and addressed early. This avoids
trainees progressing in their career without fundamental knowledge and communication skills not only
impacting on patient care but also their attainment of membership examinations and completion of their core
training.
Completion of the competency checklist is now an ARCP requirement for all new trainees to the
London Deanery. Please note that failure to complete the competency checklist can result in the
trainee being issued with an unsatisfactory outcome at ARCP.

28

29

GUIDELINES FOR TRAINERS ON CONTINUED CLOSE SUPERVISION

If competency 1 and/or 2 are not achieved close supervision in ALL areas of clinical
work will be needed
Competency not
Level of supervision
Strategies to aid the trainee to
achieved
suggested
achieve competence
1. Elicit a basic
clinical history
for a common
psychiatric
disorder

Trainee unable to elicit a

competent history should be
closely supervised when seeing
patients and all histories
checked by seniors.

The Deanery would advise
they should not undertake
unsupervised outpatient clinic
or out-of-hours work till
competency achieved.

Trainee to use resources outlined in

Trainee Handbook.
Supervision on taking a history including
components of a psychiatric history and
diagnostic questions for common
psychiatric presentations.
Trainee to observe clinical history takings
by senior colleagues and encouraged to
elicit part or all of the patient history in
joint consultations with senior colleagues.
The use of feedback through role-play
and/or video is recommended.
Consider need for support with
communication and language.

2. Perform a
mental state
examination
for a common
psychiatric
disorder

Trainee unable to perform MSE

should be closely supervised
when seeing patients and all
MSE checked by seniors.

Trainee to use resources outlined in

Trainee Handbook.

The Deanery would advise

they should not undertake
unsupervised outpatient clinic
or out-of-hours work till
competency achieved.

Trainee to observe and be observed

performing MSE with senior colleagues.

Supervision on components of MSE.

The use of feedback through role-play

and/or video is recommended.
Consider need for support with
communication and language.

29

30

If competency 1 and/or 2 have been achieved close supervision is only required in the
areas where competency has not been achieved.
Competency not
Level of supervision
Strategies to aid the trainee to
achieved
suggested
achieve competence
3. Perform a
Cognitive
Assessment

4. Perform a risk
assessment

5. Perform a
Physical
Examination

Trainee unable to demonstrate

this competency must have all
cognitive screenings cross
checked/observed by senior
colleague till competency
demonstrated.
Trainee unable to demonstrate
this competency must have all
risk assessments cross
checked/observed by senior
colleague till competency
demonstrated.
Trainee unable to demonstrate
this competency must have all
physical examinations cross
checked/observed by senior
colleague till competency
demonstrated

Trainer to identify and target where deficit

lies (e.g. ability to give clear instructions,
scoring) and to target supervision
accordingly.
Consider need for support with
communication and language.
Trainer to provide and go through with
local protocol, guidelines and forms for
risk assessment.
Consider need for support with
communication and language.
Trainee to observe and be observed
performing physical examination with
senior colleagues.
Consider need for support with
communication and language if giving
unclear instructions to patients during a
physical examination is identified.

6. Make a concise
case
presentation
and initial
management
plan for a
common
psychiatric
disorder.

Trainee unable to demonstrate

this competency must verbally
present all cases and the initial
management for patients seen
with feedback to trainee on
performance.

7. Be able to
safely
prescribe rapid
tranquilisation
in adults

Trainee unable to demonstrate

this competency to have all
drug charts cross-checked by
senior colleague until
competency has been
demonstrated.

Trainer/pharmacist to provide trainee with

local protocol and guidelines for
prescribing.

8. Write an
accurate and
concise report,
assessment or
referral

Trainee unable to demonstrate

this competency must have all
letters and reports checked by a
senior colleague before sending
out till competency has been
achieved.

Trainer to identify if deficit is due to a

deficit in language and written
communication deficit (if so consider
referral to LaCRU), or if in understanding
of psychopathology and its management.

Trainee to observe examples of concise

and accurate case presentations.
Trainee given multiple opportunities to
present cases with feedback.
Consider need for support with
communication and language.

Trainee to observe examples of concise

and accurate written communication
including letter templates and formats.
Feedback on all written communication
till competency demonstrated.
Consider need for support with
communication and language.
30

As part of the checklist assessment, your

clinical supervisor will be asked to
identify if you have any language and
communication difficulties (verbal and
written) that could affect your career
progression in psychiatry.
If this is the case, then you must identify
this as a key developmental need. This
means it is a long-term training need that
should be supported throughout your
training.

GETTING SUPPORT
FOR COMMUNICATION
& LANGUAGE
DIFFICULTIES

31

The London Deanery offers free courses for doctors and dentists to develop their language and
communication skills and improve their ability to work effectively with patients and their families, colleagues
and other professionals through the Language and Communication Resource Unit (LaCRU). All trainees who
require support will be referred to LaCRU where they are entitled up to six, 3-hour sessions.
It is important to note that if you have a language and/or communication difficulty identified, you do not have
to remain under continued close supervision if you have demonstrated all checklist clinical skills competently.

THE LANGUAGE AND COMMUNICATION RESOURCE UNIT (LaCRU)

LaCRU assists doctors and dentists working in London to improve their English language and
communication skills; enabling them to deliver the best possible care to patients and to realise their potential
working within the NHS. They offer a choice of educational modules on language, communication skills,
cultural competence and professional development.
LaCRU will also support the delivery of induction training and cultural adaptation courses for new
international medical graduates (IMGs) and EU doctors/dentists coming to work in the NHS.
THE LaCRU PROGRAMME
The programme is flexible and tailored to meet individual needs. It includes a discussion with an
educationalist and individual session(s) on language, where required. There is a choice of programme
modules, led by a medical educationalist and/ or a language specialist. Participants receive a report
outlining strengths and areas for development, which will be shared with educational and clinical supervisors
and a Personal Development Plan to help doctors/dentists to continue to develop their language,
communication and cultural competence.
To contact the LaCRU team:
London Deanery
LaCRU Coordinator
Tel:020 7862 8606
Email: [email protected]
More details including online application and useful resources available on Deanery website:
www.londondeanery.ac.uk
31

SUGGESTED READING

32

History Taking and Assessment

Burton, N., Patient Assessment, in Psychiatry. 2010. p. 11-35
Gelder M, Mayou R., Geddes J, Assessment, in Psychiatry: An Oxford Core Textbook. 2006, OUP: Oxford. p.
15-38.
Kaplan, B.J. and V.A. Sadock, History and Mental State Examination, in Kaplan and Saddock's Concise
Textbook of Clinical Psychiatry. 2003. p. 1-9.
Mental State Examination
Casey P and B. Kelly, Fish's Clinical Psychopathology: Signs and Symptoms in Psychiatry. 3rd Rev ed. 2007:
Gelder, M., R. Mayou, and J. Geddes, Signs, symptoms and diagnosis, in Psychiatry: An Oxford Core
Textbook. 2006, OUP: Oxford. p. 1-15.
Kaplan, B.J. and V.A. Sadock, History and Mental State Examination, in Kaplan and Saddock's Concise
Textbook of Clinical Psychiatry. 2003. p. 1-9.
Oyebode, F., Sims' Symptoms in the Mind: An Introduction to Descriptive Psychopathology 4th ed. 2008:
Saunders Co Ltd.
Performing cognitive screening assessment
David, A. and S. Fleminger, Mini-Mental State Examination, in Lishman's Organic Psychiatry: A Textbook of
Neuropsychiatry. 2009. p. 110-111.
Molloy, W.D., Mental Status and Neuropsychological Assessment: A guide to the Standardized Mini-Mental
State Examination, International Psychogeriatrics, Vol.9, Suppl 1, pp 87-94.
Physical Examination
Kaplan, B.J. and V.A. Sadock, Physical Illness and Psychiatric Disorders, in Kaplan and Saddock's Concise
Textbook of Clinical Psychiatry. 2003. p. 10-15.
Performing a risk assessment
Bernstein, Levin, and Poag, On Call Psychiatry. 3rd ed. 2008.
Puri, B. and I. Treasden, Aggression and Violence, in Emergencies in Psychiatry. 2008. p. 67-86.
Puri, B. and I. Treasden, Deliberate Self Harm and Suicide, in Emergencies in Psychiatry. 2008. p. 115-136.
Prescribing in psychiatry
NICE guidelines for rapid tranquillisation: http://www.nice.org.uk/nicemedia/live/10964/29716/29716.pdf
Taylor, D., C. Paton, and S. Kapur, Maudsley Prescribing Guidelines 10th Edition. 2009: Informa Healthcare.
Joint Formulary Committee, British National Formulary (BNF): Pharmaceutical Press.

32

33

LondonDeanery
THE COMPETENCY CHECKLIST IN PSYCHIATRY
Name of Trainee:
_____________________________________________________________________
Name of Clinical Supervisor(s):
_____________________________________________________________________
Date of starting post:
_____________________________________________________________________
(This checklist should be signed off with a copy sent to your TPD within 1 month of the above date)

1. Elicit a basic clinical history for a common psychiatric disorder

Trainee has demonstrated a basic ability to elicit a psychiatric history, showing an awareness of the key
areas of importance.
YOU MUST DEMONSTRATE THIS COMPETENCE BEFORE UNDERTAKING OUTPATIENT OR ON-CALL WORK INDEPENDENTLY.

How was competence assessed? e.g. toolkit OSCE, interview of an anxious patient.

Any learning objectives identified?

____________________________________________________
Assessors Name (PRINT):

_________________________________________________
Assessor Grade: SASG/ST4-6/SpR/Consultant

____________________________________________________
Assessors Signature:

_________________________________________________
Date competency was demonstrated

2. Perform a mental state examination (MSE) for a common psychiatric disorder

Trainee should demonstrate they are able to elicit the major psychopathology from a mental health patient,
showing an awareness of the components of the MSE.
YOU MUST DEMONSTRATE THIS COMPETENCE BEFORE UNDERTAKING OUTPATIENT OR ON-CALL WORK INDEPENDENTLY.

How was competence assessed? e.g. toolkit OSCE, interview of an depressed patient.

Any learning objectives identified?

____________________________________________________
Assessors Name (PRINT):

_________________________________________________
Assessor Grade: SASG/ST4-6/SpR/Consultant

____________________________________________________
Assessors Signature:

_________________________________________________
Date competency was demonstrated

33

34
3. Perform a cognitive screening assessment
Trainee must be able to perform and score a competent cognitive assessment using either MMSE or
SMMSE
How was competence assessed? e.g. toolkit OSCE, with patient.

Any learning objectives identified?

____________________________________________________
Assessors Name (PRINT):

_________________________________________________
Assessor Grade: SASG/ST4-6/SpR/Consultant

____________________________________________________
Assessors Signature:

_________________________________________________
Date competency was demonstrated

4. Perform a risk assessment

Trainee must show an awareness of the importance of historical identifiers and mental state that relate to
risk. Risk assessment must include risk to self, neglect, risk to others, risk from others.
(If using toolkit it can be linked with competency 5)

How was competence assessed? e.g. toolkit OSCE, patient interview, completion of trust risk assessment form.

Any learning objectives identified?

____________________________________________________
Assessors Name (PRINT):

_________________________________________________
Assessor Grade: SASG/ST4-6/SpR/Consultant

____________________________________________________
Assessors Signature:

_________________________________________________
Date competency was demonstrated

!
5. Make a concise case presentation and initial management plan for a common psychiatric
disorder.
Trainee must be able to summarise findings, offer a differential diagnosis, and propose an initial safe
management plan. (If using toolkit it can be linked with competency 4)
How was competence assessed? e.g. toolkit, case presentation of outpatient assessment

Any learning objectives identified?

____________________________________________________
Assessors Name (PRINT):

_________________________________________________
Assessor Grade: SASG/ST4-6/SpR/Consultant

____________________________________________________
Assessors Signature:

_________________________________________________
Date competency was demonstrated

34

35
6. Perform a Physical Examination
Trainee must demonstrate and present a reliable and appropriate physical examination (including CVS, RS,
GI, Neuro systems)
How was competence assessed?

Any learning objectives identified?

____________________________________________________
Assessors Name (PRINT):

_________________________________________________
Assessor Grade: SASG/ST4-6/SpR/Consultant

____________________________________________________
Assessors Signature:

_________________________________________________
Date competency was demonstrated

7. Be able to prescribe safely

Trainee to demonstrate they can prescribe accurately and safely and be able to prescribe rapid
tranquillisation according to local guidelines.
Assessor for this competency can be a ward/trust pharmacist.
How was competence assessed? e.g. toolkit OSCE; new patient drug chart; trust/ward induction with pharmacist

Any learning objectives identified?

____________________________________________________
Assessors Name (PRINT):

_________________________________________________
Assessor Grade: SASG/ST/SpR/Consultant/Pharmacist

____________________________________________________
Assessors Signature:

_________________________________________________
Date competency was demonstrated

8. Write an accurate and concise report, assessment or referral

Trainee should bring a clinic letter or assessment they have completed during the post. Assessor to ensure
that trainee demonstrates basic competence in language and grammar and can accurately convey relevant
clinical information with clear plan.
How was competence assessed? e.g. GP letter, discharge summary

Any learning objectives identified?

____________________________________________________
Assessors Name (PRINT):

_________________________________________________
Assessor Grade: SASG/ST4-6/SpR/Consultant

____________________________________________________
Assessors Signature:

_________________________________________________
Date competency was demonstrated

35

36

LondonDeanery
THE COMPETENCY CHECKLIST IN PSYCHIATRY
SIGN-OFF SHEET
Name of Trainee:
_____________________________________________________________________
Name of Clinical Supervisor(s):
_____________________________________________________________________
Date of starting post:
_____________________________________________________________________
TRAINER DECLARATION 1: Regarding competence in basic knowledge and skills in
psychiatry
I confirm that (tick as appropriate):
! The above trainee has been assessed by either senior colleagues or myself and demonstrated
all eight clinical competences required.
TRAINER DECLARATION 2: Regarding verbal and written communication proficiency
I confirm that (tick as appropriate):
! I have assessed the above trainees verbal and written communication and consider the
trainees language and communication skills are sufficient for their career in psychiatry.
! I have assessed the above trainees verbal and written communication and consider the trainee
to have some/significant difficulty in language and/or communication. This trainee would benefit
from this being identified as a developmental need and additional appropriate support to be put in
place.
(Please see section of the Trainer handbook for guidance on supporting trainees with communication training needs)

Signed by Clinical supervisor

Print Name

Date

Signed by Trainee

Print Name

Date

This form can be detached and should be retained by trainee for their portfolio and ARCP
Completion of the competency checklist is now an ARCP requirement for all new trainees to the London Deanery. Please note that
failure to complete the competency checklist can result in the trainee being issued with an unsatisfactory outcome at ARCP.
A copy of this page should be retained by clinical supervisor and a copy sent to TPD
!!

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