What is the template to follow for an inpatient psychiatric patient medical assessment?

Template for Inpatient Psychiatric Patient Medical Assessment

The American Psychiatric Association recommends a comprehensive psychiatric evaluation that includes specific assessment domains covering history of present illness, psychiatric history, substance use, medical history, family history, personal/social history, and mental status examination as requirements for proper psychiatric assessment. 1

Chief Complaint and History of Present Illness

• Document the patient's primary reason for admission 2
• Assess current symptoms, including onset, duration, and severity 2
• Evaluate current psychiatric symptoms including anxiety, mood changes, thought disturbances, and perceptual abnormalities 1
• Document sleep patterns and abnormalities 1

Psychiatric History

• Document past and current psychiatric diagnoses 1
• Assess prior psychotic or aggressive ideas 2
• Evaluate prior aggressive behaviors (homicide, domestic violence, workplace violence) 1
• Document prior suicidal ideas, plans, and attempts, including details of each attempt 2
• Assess prior intentional self-injury without suicidal intent 2
• Record history of psychiatric hospitalizations and emergency department visits 2
• Document past psychiatric treatments (type, duration, and doses where applicable) 2
• Assess response to past psychiatric treatments 2
• Evaluate adherence to past and current treatments 2

Substance Use History

• Assess tobacco, alcohol, and other substance use (marijuana, cocaine, heroin, hallucinogens) 2
• Document any misuse of prescribed or over-the-counter medications or supplements 2
• Evaluate current or recent substance use disorders or changes in use 2

Medical History

• Document allergies or drug sensitivities 2
• List all current and recent medications with side effects 2
• Assess relationship with primary care provider 1
• Document past or current medical illnesses and related hospitalizations 2
• Record relevant past or current treatments, including surgeries 2
• Evaluate past or current neurological or neurocognitive disorders 2
• Document physical trauma, including head injuries 2
• Assess sexual and reproductive history 2

Additional Medical Assessment

• Cardiopulmonary status 2
• Past or current endocrinological disease 2
• Past or current infectious diseases (STDs, HIV, tuberculosis, hepatitis C) 2
• Past or current conditions associated with significant pain 2

Family History

• For patients with current suicidal ideas: assess history of suicidal behaviors in biological relatives 2
• For patients with current aggressive ideas: assess history of violent behaviors in biological relatives 2
• Document relevant psychiatric and medical conditions in family members 2

Personal and Social History

• Assess psychosocial stressors (financial, housing, legal, occupational, interpersonal problems) 2
• Review trauma history 2
• Document exposure to violence or aggressive behavior 2
• Assess legal or disciplinary consequences of past aggressive behaviors 2
• Evaluate cultural factors related to social environment 2
• Assess need for an interpreter 2
• Document personal/cultural beliefs and explanations of psychiatric illness 2

Physical Examination

• Height, weight, and body mass index (BMI) 2
• Vital signs 2
• Skin examination, including stigmata of trauma, self-injury, or drug use 2
• General appearance and nutritional status 2
• Coordination and gait 2
• Involuntary movements or abnormalities of motor tone 2
• Sight and hearing assessment 2

Mental Status Examination

• Speech, including fluency and articulation 2
• Mood and level of anxiety 2
• Thought content and process 2
• Perception (hallucinations, illusions) 2
• Cognition (orientation, memory, concentration, abstract thinking) 2
• Assess hopelessness 2
• Evaluate current suicidal ideas, plans, and attempts 2
  • If present, assess:
    • Patient's intended course of action if symptoms worsen 2
    • Access to suicide methods including firearms 2
    • Possible motivations for suicide 2
    • Reasons for living 2
    • Quality of therapeutic alliance 2
• Assess current aggressive or psychotic ideas 2

Impression and Plan

• Document estimated suicide risk with influencing factors 2
• Document estimated risk of aggressive behavior with influencing factors 2
• Provide differential diagnosis 2
• Document rationale for treatment selection 2
• Include rationale for clinical tests 2
• Document treatment plan with specific interventions 2

Patient Collaboration

• Ask about treatment-related preferences 2
• Explain differential diagnosis, risks of untreated illness, treatment options, benefits and risks 2
• Document collaboration with patient about treatment decisions 2
• Consider quantitative measures of symptoms, functioning, and quality of life 2

Common Pitfalls to Avoid

• Neglecting cultural factors in assessment can lead to misdiagnosis 1
• Omitting thorough documentation of all required domains may result in incomplete assessment 1
• Failing to obtain collateral information when available and appropriate 2
• Not addressing physical health needs alongside psychiatric needs 2
• Overlooking substance use disorders that may complicate psychiatric presentation 2