Comprehensive Inpatient Psychiatric Assessment Template
A comprehensive inpatient psychiatric assessment template should include standardized sections for history of present illness, psychiatric history, substance use, medical history, family history, personal/social history, mental status examination, physical examination findings, risk assessment, impression, and treatment plan as recommended by the American Psychiatric Association. 1
Identifying Information
- Patient demographics (name, age, gender, date of birth) 1
- Date and time of evaluation 1
- Source of information (patient, family, medical records, etc.) 1
Chief Complaint/Reason for Admission
- Document the patient's own words regarding presenting problem 1
- Circumstances leading to hospitalization 1
History of Present Illness
- Psychiatric review of systems 1
- Anxiety symptoms and panic attacks 1
- Sleep patterns and abnormalities, including sleep apnea 1
- Assessment of impulsivity 1
- Chronology of symptom development 1
Psychiatric History
- Past and current psychiatric diagnoses 1
- Prior psychotic or aggressive ideas 1
- Prior aggressive behaviors (homicide, domestic violence, threats) 1
- Prior suicidal ideas, plans, and attempts (including context, method, damage, lethality, intent) 1
- Prior non-suicidal self-injury 1
- History of psychiatric hospitalizations and emergency department visits 1
- Past psychiatric treatments (type, duration, doses) 1
- Response to past treatments 1
- Adherence to past and current treatments 1
Substance Use History
- Use of tobacco, alcohol, and other substances 1
- Misuse of prescribed or over-the-counter medications 1
- Current or recent substance use disorders 1
- Changes in substance use patterns 1
- Treatment history for substance use 1
Medical History
- Allergies and drug sensitivities 1
- Current medications (prescribed, non-prescribed, supplements) 1
- Primary care relationship 1
- Past/current medical illnesses and hospitalizations 1
- Relevant past/current treatments (surgeries, procedures) 1
- Neurological or neurocognitive disorders 1
- Physical trauma, including head injuries 1
- Sexual and reproductive history 1
- Cardiopulmonary status 1
- Endocrinological disease 1
- Infectious diseases (STDs, HIV, tuberculosis, hepatitis C) 1
- Pain conditions 1
Family History
- Psychiatric disorders in biological relatives 1
- History of suicidal behaviors in relatives (especially for patients with suicidal ideation) 1
- History of violent behaviors in relatives (especially for patients with aggressive ideation) 1
- Medical conditions with potential psychiatric implications 1
Personal and Social History
- Psychosocial stressors (financial, housing, legal, occupational, relationship problems) 1
- Trauma history 1
- Exposure to violence or aggressive behavior 1
- Legal consequences of past aggressive behaviors 1
- Cultural factors related to social environment 1
- Need for interpreter 1
- Personal/cultural beliefs about psychiatric illness 1
- Educational history 1
- Occupational history 1
- Military service 1
- Relationship/marital history 1
- Living situation and support system 1
Physical Examination
- Height, weight, and BMI 1
- Vital signs 1
- Skin examination (including signs of trauma, self-injury, or drug use) 1
- General appearance and nutritional status 1
- Coordination and gait 1
- Involuntary movements or abnormalities of motor tone 1
- Vision and hearing 1
- Relevant systems examination based on presenting complaints 1
Mental Status Examination
- Appearance and behavior 1, 2
- Speech (fluency and articulation) 1
- Mood and affect 1
- Thought process (logical, tangential, circumstantial, etc.) 1, 3
- Thought content (delusions, obsessions, etc.) 1
- Perceptual disturbances (hallucinations, illusions) 1, 3
- Hopelessness assessment 1
- Cognitive assessment (orientation, memory, attention, concentration) 1, 3
- Insight and judgment 1, 3
Risk Assessment
- Current suicidal ideas, plans, and attempts 1
- Current aggressive or psychotic ideas 1
- Documented estimate of suicide risk with influencing factors 1
- Documented estimate of violence risk with influencing factors 1
Impression and Plan
- Diagnostic formulation 1
- Differential diagnosis 1
- Treatment plan with rationale 1
- Patient's treatment preferences 1
- Explanation to patient about diagnosis, risks of untreated illness, treatment options, benefits and risks 1
- Collaborative decision-making with patient 1
- Quantitative measures of symptoms, functioning, and quality of life 1
- Rationale for clinical tests 1
- Disposition plan (level of care determination) 1
- Follow-up arrangements 1
Special Considerations
- For patients with suicidal ideation, include safety planning rather than no-suicide contracts 1
- For patients with aggression, include specific assessment of triggers and response to interventions 1
- For patients with co-occurring disorders, assess problems related to both psychiatric and substance use conditions 4
- Consider using standardized assessment tools when appropriate 5