This post is about Initial Adult Psychiatric Evaluation. The points taken into consideration include Demographics, Chief Complaint, History of Present Illness, Past Psychiatric History, Substance Abuse Assessment, Medical History, Family Psychiatric and Substance History, and Developmental/Social History, among others.

Information needed to complete these notes will be gleaned from a patient interview, chart review and possibly family input.  Do NOT use an actively psychotic or demented patient who cannot provide you with this information. Try to use a patient that can supply most of the information you need so that you may only need some information from the chart or family.

Do not include any identifying data.  No names, no locations

This note will include – the demographics, the Chief Complaint, the History of Present Illness and the Past Psychiatric History, Substance Abuse Assessment and Medical History, Family Psychiatric and Substance History, the Developmental/Social History, the Mental Status Exam, a Case Formulation Section, and you will formulate your Diagnosis and a Treatment Plan.

Note E

Demographics should include: age, sex, who they live with, who they are accompanied by for your interview, who referred them to you.  Who or what is your source of data collection, reliability of the information you have obtained?  Payor source.

Chief Complaint always is stated in patients/clients own words unless they are non-verbal

History of Present Illness should include: (Chronology, Onset, Severity, Duration, Precipitating Factors) onset of current symptoms, what precipitated them, summary of current symptoms, degree of incapacity experienced, why now??  Current and premorbid level of functioning, is there any current treatment, any current comorbid medical issues or treatment.  Some do or at least begin their psychiatric review of systems here – mood, anxiety, psychosis, other (see p.198 in Kaplan and Sadock).  This is not where you get your psychiatric history.

Past Psychiatric History should include: first time they remember feeling these or any other psychiatric symptoms, ever inpatient psych treatment, first, how many, last, any of them involuntary, any suicide attempts *, homicide attempts, thoughts of either.  Have they ever seen a medication prescriber?  Have they ever seen a therapist?  Get details first time, how long, was it helpful, continuous or on and off.  Duration, type of symptoms, severity of symptoms, treatment received, response to treatment.  This does not have to be about this current diagnosis.  Can be a different diagnosis from the past.  Earlier eating disorder, did they cut?  Past medications – how long, did they work, were they compliant?

*First time, last time – how?

Substance Abuse Assessment should include: Social habits – tobacco, alcohol, drugs, gambling, sex, caffeine, eating disorders.

If alcohol is an issue – every have a blackout, seizure, tremors, treatment? Define use – how much, how often, last use, age began.  Many don’t think Rx drugs are an addiction because “my doctor prescribes them”.  Don’t forget all the new names for the new street drugs.  You need to ask very specific questions, they won’t offer.  If in recovery – how long, do they go to a support program, do they have a sponsor.  If not in recovery – what was the longest period that they have maintained sobriety and when was that.

Eating – do they binge or purge?  Do they restrict?  Do they menstruate if female?

Gambling – horses, casinos, lottery tickets, sports betting

Sex – porn, masturbation, chronic infidelity, self-described addiction

Caffeine – coffee, tea, soda, and energy drinks

Medical History should include:  past and present conditions and treatments, surgeries, traumatic injuries, serious illnesses, hospitalizations, last check-up, medications (including all OTC’s – vitamins and supplements, herbs, etc), allergies (meds, foods, environmental), availability of recent labs. This is where you need to find out if you are allowed contact with PCP if they have one.

Family Psychiatric and Substance History should include: age, education, occupation of parents, siblings, and children.  Family history of psychiatric issues or substance abuse – grandparents, aunts, uncles, cousins, both sides, blood relatives only.  If undiagnosed say that. If treated ask if they know with what. Anyone institutionalized, suicided?  Medical history only if pertinent.

Include a basic Genogram

Developmental/Social History should include: where born, where raised, did they move around, raised by whom, at what age did parents separate or divorce, siblings (whole, half, step).  Education and school history, Occupation and work history, Marital Status – sexual preference, current and past, parental status (biological, adopted, step). Relationships to spouse or partner, parents, sibs, children.  Support system in their eyes. Ever been arrested?  Ever been in the military or the spouse of military or the child of military?  Religious beliefs – current and as a child.  Financial issues.  If possible – birth info and developmental milestones.  Hobbies – likes and dislikes.  Pets.  Strengths and Weaknesses.  If applicable – sexual history.

Abuse – Sexual, Physical, Self, Emotional and Verbal.

Review of Systems – You need to do a review of body systems.  Be aware that in practice, you only need to chart abnormal findings.  Medicare now requires that we chart on musculoskeletal and gait and station, but we do not have to chart on any other system unless it is abnormal. For this assignment, I suggest including a full ROS if possible.

Mental Status Exam

• Appearance and Behavior
• Motor Activity
• Speech
• Mood
• Affect
• Thought Content (be sure to include: Motivation, Suicidal/ Homicidal, Sensorium)
• Thought Process
• Perceptual Disturbances
• Cognition – include memory, intelligence
• Abstract Reasoning
• Concentration
• Impulsivity
• Insight
• Judgement

Initial Adult Psychiatric Evaluation

Physical Examination should include results of a focused exam, which may include pulse and blood pressure, findings upon examination for rigidity, or any other focused physical assessment that may be performed.

Case Formulation Section should include: an assessment of your findings, vital signs including height and weight.  Any labs that are available or pertinent.  This is a brief summary, a discussion, almost like you are thinking out loud.  Safety assessment. What is the problem??? Is there a conscious and unconscious theme, what developmental stage are they in?  What if any are the cultural factors of this case. This is written in a narrative method.  Short and to the point.

Must include a list of your differential diagnoses!

Diagnosis should include psychiatric and medical diagnoses for this patient.  Psychiatric come first.

These must be DSM V accurate.  DSM V codes must accompany the psychiatric diagnoses. You do not need to code the visit, just the diagnosis.  You do not need to code the medical diagnoses. The justification for your diagnosis should be apparent in your case formulation section.

Strengths and deficits of the Write Up should include what went well, and what could have been improved.  For instance, perhaps it was a “text book” presentation which made for easy diagnosing, or perhaps there were details that were missing and will have to be sorted through at a later appointment.

Treatment Plan: (include these five categories):

• Pharmacology
• Diagnostic/Lab Work if indicated
• Evidence-Based Non-Pharmacological Interventions
• Patient and Family Education
• Referrals

You will need justifications for treatment decisions in  your final signature assignment.  Please cite and reference any sources used for your justification.

Initial Adult Psychiatric Evaluation

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