Components of a Comprehensive Psychiatric Consult Note
A psychiatric consult note should follow a structured format that includes comprehensive assessment of the patient's mental status, psychiatric history, risk factors, and clear treatment recommendations to optimize patient outcomes and reduce morbidity and mortality.
Essential Components
Identifying Information and Reason for Consultation
- Patient demographics (age, gender, etc.)
- Date and time of evaluation
- Referring provider and service
- Chief complaint in patient's own words
- Reason for consultation/referral 1, 2
History of Present Illness
- Duration and evolution of symptoms
- Precipitating factors and recent stressors
- What prompted seeking care now
- Current symptoms with severity and impact on functioning 1, 2
Psychiatric Review of Systems
- Mood symptoms
- Anxiety symptoms and panic attacks
- Sleep abnormalities
- Impulsivity
- Psychotic symptoms
- Cognitive symptoms
- Obsessive-compulsive symptoms
- Post-traumatic symptoms 1, 2
Psychiatric History
- Past and current psychiatric diagnoses
- Prior psychiatric hospitalizations and emergency department visits
- Past psychiatric treatments (type, duration, doses)
- Response to past treatments
- Adherence to past and current treatments
- Prior suicidal ideas, plans, and attempts (with details of each attempt)
- Prior self-injury without suicidal intent
- Prior psychotic or aggressive ideas/behaviors 1, 2
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
Medical History
- Allergies and drug sensitivities
- Current medications (prescribed and non-prescribed) and side effects
- Primary care relationship
- Past/current medical illnesses and hospitalizations
- Past/current treatments, surgeries, procedures
- Neurological/neurocognitive disorders
- Physical trauma, including head injuries
- Sexual and reproductive history 1
- Consider additional assessment of:
- Cardiopulmonary status
- Endocrinological disease
- Infectious diseases
- Pain conditions 1
Family History
- Psychiatric disorders in biological relatives
- History of suicidal behaviors in relatives (especially for patients with current suicidal ideas)
- History of violent behaviors in relatives (especially for patients with current aggressive ideas) 1, 2
Personal and Social History
- Psychosocial stressors (financial, housing, legal, occupational, interpersonal)
- Trauma history
- Exposure to violence or aggressive behavior
- Legal consequences of past aggressive behaviors
- Cultural factors related to social environment
- Need for interpreter
- Personal/cultural beliefs about psychiatric illness 1
Mental Status Examination
- Appearance and general behavior
- Motor activity and coordination
- Speech (fluency and articulation)
- Mood (subjective emotional state)
- Affect (observed emotional expression)
- Thought process (organization, coherence)
- Thought content (delusions, obsessions, preoccupations)
- Perceptual disturbances (hallucinations)
- Cognition (orientation, memory, concentration, abstraction)
- Insight and judgment 1, 2
Physical Examination Elements
- Vital signs
- Height, weight, BMI
- Skin examination (including signs of trauma, self-injury, substance use)
- Coordination and gait
- Involuntary movements or abnormalities of motor tone
- Sensory function 1, 2
Risk Assessment
- Current suicidal ideas, plans, and attempts
- Access to suicide methods (especially firearms)
- Patient's intended course of action if symptoms worsen
- Motivations for suicide
- Protective factors and reasons for living
- Hopelessness assessment
- Current aggressive or psychotic ideas
- Risk factors for violence 1, 2
Diagnostic Formulation
- DSM diagnosis or provisional diagnosis
- Medical conditions contributing to psychiatric presentation
- Differential diagnosis
- Estimated suicide risk with factors influencing risk
- Estimated risk of aggressive behavior 1, 2
Treatment Plan and Recommendations
- Rationale for treatment selection
- Specific pharmacological recommendations (if indicated)
- Psychotherapeutic interventions
- Level of care recommendations
- Safety planning
- Follow-up arrangements
- Coordination with other providers
- Patient education about diagnosis, risks, and treatment options
- Documentation of patient's treatment preferences 1, 2, 3
Important Considerations
Medical Causes of Psychiatric Symptoms
- Always consider medical conditions that may present with psychiatric symptoms 4
- Document rationale for clinical tests ordered 1
Documentation Format
- Follow SOAP (Subjective, Objective, Assessment, Plan) format 2
- Use clear, concise language
- Avoid psychiatric jargon when writing for non-psychiatric colleagues 5, 6
Risk Management
- Document suicide risk assessment thoroughly
- For patients on antidepressants, note monitoring plan for emergence of suicidality 3
- For elderly patients with dementia, document discussion of increased mortality risk with antipsychotics 3
- Include safety planning and follow-up arrangements 1, 2
Common Pitfalls to Avoid
- Failing to document a complete mental status examination with all nine core domains 2
- Omitting medical causes of psychiatric symptoms 4
- Inadequate risk assessment for suicide or violence 1, 2
- Vague or non-specific recommendations 5, 6
- Failing to screen for bipolar disorder in patients presenting with depression 3
- Not documenting the rationale for treatment decisions 1
By following this structured approach, psychiatric consultants can provide comprehensive evaluations that address both mental health needs and medical considerations, ultimately improving patient outcomes and reducing morbidity and mortality.