Psychiatric Evaluation

Identifying data
Source and reliability
Chief complaint

1. How may I help you today?

HPI

1. What were the circumstances that led to your coming here today?
2. When did this start?
3. Specific details about particular symptoms
4. Past or present: Suicidal ideation? Homicidal ideation? Psychotic symptoms
(hearing voices, having strange thoughts)?
a. Have you ever attempted suicide, or felt like you would be better off
being dead?
b. What happened, planning, lethality, intent, hospitalized? Regret?
Voices?
c. What would you do if you had those thoughts again?
d. Are you now or have you ever had thoughts of harming another
person? Have you ever been arrested? Got in trouble for fighting?
e. Anger management? How quickly do you feel like you get angry?
5. Head trauma? Substance abuse? Physical symptoms.

Past psych hx

1. Past diagnoses/hospitalizations/treatment/medications
2. Family psych hx
3. Drugs/alcohol

Medical surgical hx, meds, doses, indications, OTC’s

1. Allergies, reactions?
2. Supplements?
3. Has there ever been a time when you used a drug or medication that wasn’t
prescribed to you?
a. What? How? How much? HOw often?
b. Attempts at quitting, successes, failures?
c. Current use?
d. Alcohol
e. Drugs, including designer drugs
f. Prescription medications
g. Marijuana and tobacco
h. Caffeine, energy drinks, herbal supplements.
4. Current and past medical illnesses/symptoms and treatments, dates
5. Past surg
6. Current meds
7. Head injuries
8. Pregnancies
9. HIV or HIV risk
Family med hx

1. Psych: suicides, suicide attempts, disorders, treatments, ECT, medication side

FX
2. Substances: drugs, alcohol, sobriety?
3. Family med hx: tx, deaths

Developmental and social hx

1. Developmental:
a. Who was in your household growing up?
b. What were things like in your household growing up?
c. Neglect, abuse, household challenges
d. Academic/behavior problems/disabilities/special classes/friends/sports
e. Relationship history (abuse, attachment, intimacy)
f. Live events (graduations, deaths, accidents, traumas, moves, legal)
2. Employment, education
3. Treatment coverage
4. Offspring/supports
5. Household
6. Sexual hx
7. Habits (alcohol, drugs, tobacco, prescription abuse, energy drinks)
8. Occupation
9. Travel
10. Spiritual/religious
11. Legal
12. Military

Review of systems

1. Medical symptoms
2. Cop out...Are your vital signs normal? Heart and lungs normal?
3. Sad
4. Interest lost
5. Guilt
6. Energy
7. Concentration
8. Appetite
9. Psychomotor
10. Sleep/suicidal ideation

Mental status exam (popped out)

1. Appearance:
2. Orientation:
3. Behavior:
4. Eye Contact:
5. Affect:
6. Mood:
7. Speech:
 8. Thought content:
9. Thought process:
10. Cognitive:
11. Estimate intelligence/insight/judgment

Is there anything else I should know about you that would help me understand you and what
you’ve been through?
How would you know if you were doing better? (What is the patient’s expectation of a better
outcome? Write it down, reference it at the next visit so the patient can measure their own
success.)

Also to be included in the write-up??

Physical exam
Formulation
DSM-5 diagnoses
Treatment plan

Mini Mental Status Exam

Biopsychosocial formulation for the patient’s current presentation

5-diagnosis DDx:

Did your diagnosis differ? Why? What complicated this?

Peer eval including: Timeliness, professionalism, listening skills/non-judgmental questioning

Assigned name and ALA time slot