Key Components of a Standard Psychiatric Assessment
A standard psychiatric assessment must include a comprehensive evaluation of the patient's psychiatric symptoms, history, mental status examination, risk assessment, and treatment planning to ensure proper diagnosis and effective care management. 1, 2
Core Components of Psychiatric Assessment
1. History of Present Illness
- Chief complaint and reason for presentation
- Psychiatric review of systems, including:
- Anxiety symptoms and panic attacks
- Sleep abnormalities (including sleep apnea)
- Assessment of impulsivity 1
2. Psychiatric History
- Past and current psychiatric diagnoses
- Prior psychotic or aggressive ideas
- Prior aggressive behaviors
- Suicidal history:
- Prior suicidal ideas, plans, and attempts
- Details of each attempt (context, method, damage, lethality, intent)
- Prior intentional self-injury without suicidal intent
- Treatment history:
- Psychiatric hospitalizations and emergency visits
- Past treatments (type, duration, doses)
- Response to past treatments
- Treatment adherence 1
3. Substance Use History
- Use of tobacco, alcohol, and other substances
- Misuse of prescribed or over-the-counter medications
- Current or recent substance use disorders 1
4. Medical History
- Allergies and drug sensitivities
- Current medications and side effects
- Primary care relationship
- Relevant medical conditions 1
5. Social and Developmental History
- Family psychiatric history
- Personal history
- Exposure to violence or abuse
- Legal history
- Cultural factors
- Need for interpreter 1
6. Mental Status Examination
The objective section should include assessment of:
- Appearance and general presentation
- Behavior and psychomotor activity
- Speech characteristics
- Mood and affect
- Thought process
- Thought content
- Perceptual disturbances
- Cognition (orientation, memory, concentration)
- Insight and judgment 2, 3
7. Physical Examination Elements
- Height, weight, BMI
- Vital signs
- Skin examination (including signs of trauma or self-injury)
- Coordination and gait
- Involuntary movements
- Sensory function 1
8. Risk Assessment
- Suicide risk assessment:
- Current suicidal ideas, plans, and attempts
- Access to means
- Motivations for suicide
- Reasons for living
- Intended course if symptoms worsen
- Violence risk assessment:
9. Assessment and Diagnosis
- Current psychiatric diagnoses or differential diagnoses
- Documentation of risk factors
- Functional impairments
- Rationale for treatment selection 1, 2
10. Treatment Planning
- Comprehensive, person-centered treatment plan
- Evidence-based interventions (pharmacological and non-pharmacological)
- Safety planning
- Follow-up arrangements
- Coordination with other providers
- Patient education 2
Best Practices for Documentation
- Use standardized SOAP format (Subjective, Objective, Assessment, Plan)
- Document specific observations rather than vague generalizations
- Include direct quotes when relevant
- Consider cultural factors that influence presentation
- Document quantitative measures of symptoms when appropriate
- Include the patient's treatment preferences
- Explain diagnosis, risks, and treatment options to the patient
- Document collaborative decision-making 1, 2
Common Pitfalls to Avoid
- Incomplete risk assessments
- Vague documentation language
- Failure to document follow-up plans
- Neglecting to assess for hopelessness when suicidal ideation is present
- Overlooking cultural factors
- Omitting documentation of the rationale for clinical decisions 2
A thorough psychiatric assessment may require multiple sessions depending on the complexity of the case, clinical setting, and patient's ability to cooperate. The evaluation should incorporate information from multiple sources, including direct patient interview, medical records, physical examination, diagnostic testing, and collateral sources 1.