Assessment of History of Present Illness (HPI) for Psychiatric Follow-up Appointment
This HPI is comprehensive and appropriate for a psychiatric follow-up appointment, capturing essential clinical information about the patient's current symptoms, medication regimen, and safety concerns.
Strengths of the HPI
The HPI effectively documents the patient's current medication regimen (Lamictal 50mg daily, Lithium 1200mg daily, and cross-tapering from Risperidone to Lurasidone), which is essential for medication management in psychiatric care 1.
The documentation clearly describes the patient's psychiatric symptoms, including auditory and visual hallucinations, paranoid ideation, and suicidal thoughts, which are critical for assessing the patient's current mental status 1.
The HPI appropriately notes the patient's living situation, self-care abilities, and impact of symptoms on daily functioning, which provides important context for treatment planning 1.
The documentation includes a safety assessment with mention of suicidal ideation without plan or intent, and notes that a safety plan was reviewed with the patient 1.
The HPI documents the clinician's recommendation for a higher level of care (inpatient treatment) based on worsening symptoms and concerns about medication adherence 1.
Areas for Enhancement
The HPI could benefit from more specific details about the frequency, duration, and intensity of the auditory and visual hallucinations, particularly since the patient reports these are worsening 1.
More information about the patient's sleep patterns beyond "sleeps well" would be valuable, as sleep disturbances are common in psychiatric disorders and can affect symptom severity 1.
Documentation of vital signs and a brief physical examination would strengthen the HPI, particularly given the patient is on Lithium which requires monitoring for side effects 1, 2.
The HPI mentions marijuana use but does not provide details about frequency, amount, or pattern of use, which is important when assessing substance use in psychiatric patients 1.
More specific information about medication adherence would be helpful, especially since poor adherence is mentioned as a concern 1, 3.
Best Practices for Psychiatric Follow-up HPI
Include a structured assessment of all major symptom domains: cognition, mood, psychosis, anxiety, substance use, and functional status 1.
Document medication adherence, side effects, and response to treatment in detail 1, 2.
Note any changes in symptoms or functioning since the previous appointment 1.
Include a thorough safety assessment with specific details about suicidal or homicidal ideation 1.
Document the rationale for treatment decisions, including medication changes or recommendations for higher levels of care 1.
Include information about the patient's support system and living situation as these factors impact treatment planning 1.
In conclusion, this HPI provides a good foundation for clinical decision-making in this psychiatric follow-up appointment, though additional details in certain areas would further enhance its comprehensiveness 1.