What should be included in a fillable psychiatric diagnostic evaluation template for inpatients, including mental status exam and physical exam?

Comprehensive Psychiatric Diagnostic Evaluation Template for Inpatients

A standardized psychiatric diagnostic evaluation for inpatients should include a structured mental status examination and targeted physical examination components to ensure comprehensive assessment of psychiatric conditions while identifying potential medical causes of psychiatric symptoms.

Demographic Information

• Patient name, age, gender, date of birth
• Date of admission
• Medical record number
• Insurance information
• Primary care provider
• Referring provider
• Legal status (voluntary/involuntary)

Chief Complaint

• Primary reason for admission in patient's own words
• Duration of current symptoms

History of Present Illness

• Onset, duration, and progression of symptoms
• Recent stressors or precipitating events
• Current symptoms (severity, frequency, duration)
• Impact on functioning
• Previous similar episodes
• Recent medication changes or non-adherence
• Recent substance use patterns
• Current risk assessment:
  • Suicidal ideation, plan, intent, attempts 1
  • Homicidal ideation, plan, intent, history of violence 1
  • Self-harm behaviors without suicidal intent 1

Psychiatric History

• Past psychiatric diagnoses 1
• Previous psychiatric hospitalizations and ED visits 1
• Previous outpatient treatment
• Past psychiatric medications (type, duration, dosage, response, side effects) 1
• History of suicide attempts (include method, intent, context) 1
• History of violence or aggressive behaviors 1
• Treatment adherence history 1

Substance Use History

• Current and past use of:
  • Tobacco/nicotine products
  • Alcohol (quantity, frequency, last use)
  • Illicit substances (type, route, quantity, frequency, last use)
  • Prescription medication misuse
  • Over-the-counter medication or supplement misuse 1
• History of withdrawal symptoms
• History of substance-induced psychiatric symptoms
• Previous substance use treatment
• Impact of substance use on functioning

Medical History

• Allergies and drug sensitivities 1
• Current medications (prescribed and non-prescribed) 1
• Primary care provider relationship 1
• Past/current medical conditions 1
• Previous hospitalizations and surgeries 1
• Neurological disorders or symptoms 1
• History of head injuries 1
• Sexual and reproductive health history 1
• Relevant systems review:
  • Cardiopulmonary status 1
  • Endocrine disorders 1
  • Infectious diseases (HIV, hepatitis, STIs, TB) 1
  • Pain conditions 1

Family History

• Psychiatric disorders in biological relatives
• Substance use disorders in family
• Suicide attempts or completions in family 1
• History of violence in family (especially for patients with aggressive ideation) 1
• Medical conditions with psychiatric presentations
• Family support structure

Psychosocial History

• Living situation
• Educational background
• Occupational history
• Financial status
• Legal history
• Military service
• Cultural and spiritual factors 1
• Sexual orientation and gender identity
• Relationship status and quality
• Support systems
• Trauma history (childhood abuse, combat exposure, etc.) 1
• Current psychosocial stressors 1
• Need for interpreter services 1

Mental Status Examination (MSE)

Appearance and Behavior

• General appearance (grooming, hygiene, nutritional status) 2
• Posture and gait
• Eye contact
• Psychomotor activity (agitation, retardation, abnormal movements)
• Level of cooperation with examination 2
• Attitude toward examiner

Speech

• Rate, rhythm, volume
• Prosody and articulation
• Quantity (verbose, poverty of speech)
• Spontaneity

Mood and Affect

• Self-reported mood 2
• Observed affect (range, appropriateness, intensity, stability)
• Presence of anxiety symptoms 1

Thought Process

• Organization (logical, circumstantial, tangential, flight of ideas)
• Coherence and goal-directedness
• Thought blocking or insertion
• Racing thoughts

Thought Content

• Suicidal or homicidal ideation (detailed assessment)
• Delusions (type, fixity)
• Obsessions
• Phobias
• Preoccupations
• Hopelessness 2

Perception

• Hallucinations (auditory, visual, tactile, olfactory, gustatory)
• Illusions
• Depersonalization/derealization

Cognition

• Level of consciousness
• Orientation (person, place, time, situation)
• Attention and concentration
• Memory (immediate, recent, remote)
• Abstract thinking
• Calculation abilities
• Language functions
• Visuospatial abilities
• Executive functioning
• Consider using validated tools:
  • Mini-Mental State Examination (MMSE) 2
  • Montreal Cognitive Assessment (MoCA) 2
  • Mini-Cog 2
  • Confusion Assessment Method (CAM) for delirium 2

Insight and Judgment

• Awareness of illness
• Understanding of need for treatment
• Ability to make reasonable decisions
• Capacity assessment if indicated

Physical Examination Pertinent to Psychiatry

• Vital signs (temperature, pulse, blood pressure, respiratory rate) 1
• Height, weight, BMI 1
• General appearance
• Skin examination (self-injury marks, injection sites, rashes) 1
• Neurological examination:
  • Cranial nerves
  • Motor function (strength, tone)
  • Sensory function
  • Reflexes
  • Coordination
  • Gait
  • Abnormal movements (tremor, dyskinesia, dystonia)
• Signs of substance intoxication or withdrawal
• Evidence of medical conditions that may present with psychiatric symptoms 1

Medical Clearance Assessment

• Focused medical assessment based on history and physical examination findings 1
• Routine laboratory testing is not recommended for all psychiatric patients but should be guided by clinical presentation 1
• Consider targeted testing based on:
  • New-onset psychiatric symptoms
  • Abnormal vital signs
  • Abnormal physical examination findings
  • History of medical conditions
  • Age (elderly patients may require more thorough evaluation)
  • Substance use history
  • Medication effects

Diagnostic Formulation

• Primary psychiatric diagnosis (DSM-5 criteria)
• Differential diagnosis
• Rule-out medical causes of psychiatric symptoms
• Contributing psychosocial factors
• Risk assessment summary

Treatment Plan

• Immediate interventions for safety concerns
• Medication recommendations
• Psychotherapeutic approaches
• Medical interventions if needed
• Psychosocial interventions
• Discharge planning considerations
• Follow-up recommendations

Common Pitfalls to Avoid

• Overlooking medical causes of psychiatric symptoms, especially in:
  • First-episode psychosis
  • Elderly patients
  • Patients with substance use disorders
  • Patients with abnormal vital signs 1
• Relying solely on cognitive screening tools without clinical judgment 2
• Neglecting cultural factors in symptom presentation and interpretation 2
• Failing to obtain collateral information from family/caregivers 2
• Assuming lack of capacity based on diagnosis alone 2
• Ordering unnecessary laboratory and imaging studies 1

This template provides a comprehensive framework for psychiatric evaluation of inpatients while focusing on elements most relevant to identifying medical conditions that may present with psychiatric symptoms or complicate psychiatric treatment.