What should be included in a psychiatric consult note?

Components of a Comprehensive Psychiatric Consult Note

A comprehensive psychiatric consult note should include assessment of mental status, psychiatric history, substance use, medical history, family history, personal/social history, physical examination findings, risk assessment, impression, and treatment plan as recommended by the American Psychiatric Association.

Identifying Information and Chief Complaint

• Patient demographics (age, gender, marital status)
• Referral source and reason for consultation
• Chief complaint documented in patient's own words
• Duration of symptoms and precipitating factors

History of Present Illness

• Chronological development of symptoms
• Current psychiatric symptoms with onset, duration, and severity
• Recent stressors or life changes
• Previous treatments and responses

Psychiatric History

• Past and current psychiatric diagnoses 1
• Prior psychiatric hospitalizations and emergency department visits
• Past psychiatric treatments (type, duration, doses) and response
• Adherence to past and current treatments
• Prior suicidal ideas, plans, attempts (including details of method, intent, lethality) 1
• Prior self-injury without suicidal intent
• Prior aggressive behaviors or homicidal ideation 1

Substance Use History

• Detailed assessment of tobacco, alcohol, and other substances
• Prescription medication misuse or over-the-counter supplements
• Current or recent substance use disorders 1
• Changes in substance use patterns

Medical History

• Allergies and drug sensitivities
• Current medications and side effects
• Primary care relationship status
• Past/current medical conditions and hospitalizations
• Relevant treatments, surgeries, procedures
• Neurological disorders or symptoms
• Physical trauma, especially head injuries
• Sexual and reproductive history 1

Family History

• Psychiatric disorders in biological relatives
• History of suicidal behaviors in relatives (especially for patients with current suicidal ideas) 1
• History of violent behaviors in relatives (for patients with aggressive ideas) 1

Personal and Social History

• Psychosocial stressors (financial, housing, legal, occupational, relationship)
• Social support assessment
• 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, 2

Mental Status Examination

The mental status examination must include assessment of:

1. General appearance and nutritional status
2. Coordination, gait, and motor function
3. Speech characteristics (fluency, articulation)
4. Mood and level of anxiety
5. Affect (observable emotional expression)
6. Thought content and process
7. Perception (hallucinations, illusions)
8. Cognition (orientation, memory, concentration)
9. Hopelessness assessment
10. Insight and judgment 1, 2

Additional physical assessment should include:

• Height, weight, BMI
• Vital signs
• Skin examination (trauma, self-injury, drug use signs) 1

Risk Assessment

Suicide Risk Assessment

• Current suicidal ideas, plans, attempts
• Access to suicide methods, especially firearms
• Motivations for suicide
• Protective factors and reasons for living
• Quality of therapeutic alliance 1

Violence Risk Assessment

• Current aggressive or psychotic ideas
• Thoughts of physical/sexual aggression or homicide
• Risk factors for violence 1

Diagnostic Testing

• Quantitative symptom measures
• Cognitive assessment results
• Laboratory or imaging findings
• Other relevant test results 1

Impression and Diagnosis

• Diagnostic formulation with DSM criteria
• Differential diagnosis considerations
• Estimated suicide risk with influencing factors
• Estimated risk of aggressive behavior 1

Treatment Plan

The plan section must include:

1. Rationale for treatment selection
2. Discussion of specific factors influencing treatment choice
3. Patient's treatment preferences
4. Explanation of differential diagnosis, risks of untreated illness, treatment options, benefits and risks
5. Evidence-based pharmacological recommendations
6. Evidence-based non-pharmacological interventions
7. Safety planning
8. Follow-up arrangements
9. Coordination with other providers 1, 2

Common Pitfalls to Avoid

• Failing to document suicide risk assessment
• Incomplete mental status examination (missing key domains)
• Inadequate assessment of substance use
• Overlooking medical conditions that may present with psychiatric symptoms
• Not addressing patient treatment preferences
• Missing documentation of risk factors for violence when aggressive ideas are present
• Failing to explain treatment rationale and options to patients 1, 2

By following this structured approach, psychiatrists can ensure comprehensive assessment, accurate diagnosis, and appropriate treatment planning that prioritizes patient safety and well-being.