Comprehensive Psychiatric Evaluation Template
A comprehensive psychiatric evaluation should follow the American Psychiatric Association's 2015 Practice Guidelines structure, which provides a systematic framework for documenting all essential components of the initial assessment 1.
Header Information
Document the following identifying elements:
- Patient name, date of birth, medical record number
- Date and time of evaluation
- Evaluator name and credentials
- Location of evaluation
Chief Complaint
Record the patient's stated reason for seeking evaluation in their own words.
History of Present Illness
The APA mandates assessment of psychiatric review of systems, including anxiety symptoms and panic attacks, sleep abnormalities (including sleep apnea), and impulsivity 1.
Document:
- Onset, duration, and progression of current symptoms
- Precipitating factors and context
- Impact on functioning (work, relationships, self-care)
- Previous episodes and patterns
- Current stressors
Psychiatric History
Document all past and current psychiatric diagnoses, prior suicidal ideation/attempts (including aborted or interrupted attempts with details of context, method, damage, potential lethality, and intent), prior intentional self-injury without suicidal intent, and prior psychotic or aggressive ideas 1.
Include:
- History of psychiatric hospitalizations and emergency department visits
- All past psychiatric treatments (type, duration, doses)
- Response to past treatments
- Adherence to past and current pharmacological and non-pharmacological treatments
- Prior aggressive behaviors (homicide, domestic violence, workplace violence, other physically or sexually aggressive threats or acts)
Substance Use History
The APA requires assessment of tobacco, alcohol, and other substance use (marijuana, cocaine, heroin, hallucinogens), misuse of prescribed or over-the-counter medications or supplements, and current or recent substance use disorder or changes in use 1.
Medical History
Document allergies or drug sensitivities; all current and recent medications with side effects (prescribed, non-prescribed, herbal supplements, vitamins); relationship with primary care provider; past/current medical illnesses and hospitalizations; relevant treatments including surgeries and complementary therapies; neurological or neurocognitive disorders; physical trauma including head injuries; and sexual/reproductive history 1.
The APA also suggests documenting:
- Cardiopulmonary status
- Endocrinological disease
- Infectious diseases (sexually transmitted diseases, HIV, tuberculosis, hepatitis C, locally endemic infections like Lyme disease)
- Conditions associated with significant pain and discomfort
Family History
For patients with current suicidal ideas, document history of suicidal behaviors in biological relatives; for patients with aggressive ideas, document history of violent behaviors in biological relatives 1.
Include psychiatric and medical illnesses in first-degree relatives.
Personal and Social History
The APA mandates assessment of psychosocial stressors (financial, housing, legal, school/occupational, interpersonal problems, lack of social support, painful/disfiguring/terminal medical illness), trauma history, exposure to violence or aggressive behavior (combat exposure, childhood abuse), legal or disciplinary consequences of past aggressive behaviors, cultural factors related to social environment, and need for an interpreter 1.
Document:
- Developmental history
- Educational and occupational history
- Relationship history
- Living situation
- Support system
- Cultural/religious background and beliefs about psychiatric illness
Mental Status Examination
The APA requires assessment of general appearance and nutritional status; coordination and gait; involuntary movements or abnormalities of motor tone; sight and hearing; speech including fluency and articulation; mood, anxiety level, thought content and process, perception and cognition; and hopelessness 1.
The APA also suggests documenting:
- Height, weight, body mass index (BMI)
- Vital signs
- Skin (stigmata of trauma, self-injury, drug use)
Detailed Mental Status Components:
- Appearance: Grooming, hygiene, dress, apparent age
- Behavior: Eye contact, cooperation, psychomotor activity
- Speech: Rate, volume, tone, fluency, articulation
- Mood: Patient's subjective report
- Affect: Observed emotional expression (range, appropriateness, stability)
- Thought Process: Organization, coherence, flow
- Thought Content: Preoccupations, obsessions, delusions
- Perceptual Disturbances: Hallucinations, illusions
- Cognition: Orientation, attention, concentration, memory
- Insight: Understanding of illness
- Judgment: Decision-making capacity
Risk Assessment
The APA mandates documentation of current suicidal ideas, plans, and attempts (active or passive thoughts of suicide or death) 1.
If Suicidal Ideas Present, Assess:
- Patient's intended course of action if symptoms worsen
- Access to suicide methods including firearms
- Possible motivations (attention, reaction from others, revenge, shame, humiliation, delusional guilt, command hallucinations)
- Reasons for living (sense of responsibility to children/others, religious beliefs)
- Quality and strength of therapeutic alliance
Document current aggressive or psychotic ideas, including thoughts of physical or sexual aggression or homicide 1.
The APA requires documentation of an estimate of suicide risk with factors influencing risk, and suggests documentation of estimated risk of aggressive behavior (including homicide) with influencing factors 1.
Diagnostic Formulation
Provide DSM-5 diagnoses on all applicable axes, including:
- Primary psychiatric diagnosis
- Contributing medical conditions
- Psychosocial and environmental problems
- Assessment of functioning
Treatment Plan
The APA mandates documentation of the rationale for treatment selection, including specific factors that influenced the treatment choice 1.
The evaluation must include asking the patient about treatment-related preferences; explaining the differential diagnosis, risks of untreated illness, treatment options, and benefits/risks of treatment; and collaboration between clinician and patient about treatment decisions 1.
Include:
Pharmacotherapy:
- Specific medications with rationale
- Target symptoms
- Dosing strategy
- Monitoring plan for efficacy and side effects
Psychotherapy:
- Modality (CBT, DBT, psychodynamic, supportive, etc.)
- Frequency and duration
- Specific goals
Referrals:
- Medical specialists
- Substance abuse treatment
- Social services
- Case management
Goals:
- Short-term (symptom reduction, safety)
- Long-term (functional improvement, quality of life)
Follow-up:
- Specific timeframe for next appointment
- Crisis plan and emergency contacts
- Parameters for urgent re-evaluation
The APA suggests including quantitative measures of symptoms, level of functioning, and quality of life, and documentation of the rationale for clinical tests 1.
Common Pitfalls to Avoid
- Incomplete risk assessment: Always document both suicidal AND aggressive ideation with specific details about access to means, particularly firearms
- Missing collateral information: When available, incorporate information from family, prior providers, and medical records
- Inadequate substance use history: Specifically ask about each substance category and prescription medication misuse
- Overlooking medical contributors: Screen for neurological, endocrine, infectious, and other medical conditions that may contribute to psychiatric symptoms
- Cultural insensitivity: Document cultural factors, need for interpreter, and patient's cultural explanations of illness
- Vague treatment rationale: Explicitly state why specific treatments were chosen over alternatives