Well it sounds like you should be good with caring for them-- again I always just worry about safety. As far as notes.....Do you actually have to do a mental health eval? a lethality assessment? I would find out from your agency what they require to start with. They may expect you to do that or not want you to....hard to say. Are you there specifically for their psych dx? or for medical?
What I would do is a basic eval just to document: mood, affect, any reported or observed signs of A/V hallucinations, any delusional thinking, thought process, any SI or HI, motor function (psychomotor agitation, etc.), speech pattern, INSIGHT and JUDGEMENT probably important as a lack of either or both could support need for continued support. Also important might be to discuss what supports the ct does have as lack of supports (family, friends, community programs, etc) would also support need for continued support. A mention of the cts ability to keep up with ADLs/IADLs or not could help in supporting that need for continued care. Meds. If the ct has been med-compliant. Check the medi-set if they use one to note anything that could indicate need for more support with meds (ie-the pills all mixed up from the way you put them--looking like they dropped the box but didn't! lol) Compliant with treatment/psych appts? oh and Coping skills, safety plan, etc. can be mentioned when talking about support. Oh and last thought....document how the ct is tolerating meds....any side effects, EPS, etc. and a set of vitals. you can document sleep too, and if normal or any problems. If they are diabetic and on any of the second generation anti-psychotics-- you can note how the BGs have been, and I would do a weight occasionally and document it for these folks. Those meds can cause probs with weight and glucose levels. Some docs do HGA1C now and then on them to monitor.
This is the kind thing that comes to mind--......I know its not in formal format but I hope this helps. If you need help with the mental health eval part there are a lot of books out there and probably stuff on line.
But overall if you can support in your note that the ct continues to need support or assistance with things due to their chronic mental health dx and show why-evidence- you should be okay. Hope this was helpful. Good luck.