Comprehensive Template for History of Present Illness (HPI) in Psychiatric Evaluation
A comprehensive psychiatric HPI should include a detailed assessment of the patient's presenting symptoms, psychiatric review of systems, past psychiatric history, substance use history, medical history, family history, and personal/social history to ensure proper diagnosis and effective treatment planning.
Core Components of Psychiatric HPI
1. Chief Complaint and Reason for Presentation
- Document the patient's primary concern in their own words
- Include duration of symptoms and what prompted seeking care now
- Note any precipitating factors or recent stressors
2. Psychiatric Review of Systems 1, 2
- Anxiety symptoms and panic attacks
- Sleep abnormalities (including sleep apnea)
- Impulsivity assessment
- Mood symptoms (depression, mania, hypomania)
- Psychotic symptoms (hallucinations, delusions)
- Cognitive symptoms (attention, memory, concentration)
- Obsessive-compulsive symptoms
- Post-traumatic symptoms
3. Psychiatric History 1, 2
- 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 department visits
- Past psychiatric treatments (type, duration, doses)
- Response to past treatments
- Adherence to past and current treatments
4. Substance Use History 1, 2
- Current and past use of:
- Tobacco
- Alcohol
- Cannabis
- Stimulants (cocaine, methamphetamine)
- Opioids
- Hallucinogens
- Sedatives
- Misuse of prescribed or over-the-counter medications
- History of substance use disorders
- Recent changes in substance use patterns
- Impact of substance use on functioning
5. Medical History 1, 2
- Allergies and drug sensitivities
- Current medications (prescribed, non-prescribed, supplements)
- Primary care relationship
- Past/current medical conditions and hospitalizations
- Past/current treatments (surgeries, procedures, alternative treatments)
- Neurological or neurocognitive disorders
- Physical trauma, including head injuries
- Sexual and reproductive history
- Consider documenting:
- Cardiopulmonary status
- Endocrinological diseases
- Infectious diseases
- Pain conditions
6. Family History 1, 2
- Family history of psychiatric disorders
- Family history of suicide (especially for patients with suicidal ideation)
- Family history of violence (especially for patients with aggressive ideation)
- Family history of substance use disorders
7. Personal and Social History 1, 2
- Psychosocial stressors:
- Financial problems
- Housing issues
- Legal problems
- School/occupational difficulties
- Interpersonal/relationship problems
- Lack of social support
- Trauma history
- Exposure to violence or aggressive behavior
- Legal or disciplinary consequences of past behaviors
- Cultural factors related to social environment
- Need for interpreter
- Personal/cultural beliefs about psychiatric illness
Risk Assessment Elements 1, 2
Suicide Risk Assessment
- Current suicidal ideas, plans, and attempts
- Access to means
- Motivations for suicide
- Intended course of action if symptoms worsen
- Protective factors and reasons for living
- Hopelessness assessment
Violence Risk Assessment
- Current aggressive or psychotic ideas
- Risk factors for violence
- Access to weapons
- History of violence
Documentation Best Practices 2
- Use specific observations rather than vague generalizations
- Include direct quotes from the patient when relevant
- Document cultural factors that may influence presentation
- Use quantitative measures of symptoms when possible
- Ensure chronological organization of symptoms and events
- Document functional impairments related to symptoms
Common Pitfalls to Avoid
- Failing to assess for bipolar disorder in patients presenting with depression 3
- Neglecting to document substance use patterns that may affect presentation
- Overlooking medical conditions that may present with psychiatric symptoms
- Insufficient documentation of risk assessment
- Not exploring treatment history in sufficient detail
- Neglecting to document the chronological development of symptoms
By following this comprehensive template, clinicians can ensure they gather all essential information needed for accurate diagnosis, risk assessment, and effective treatment planning in psychiatric evaluations.