Writing an HPI for a Follow-Up Psychiatric Note
The most effective approach for writing a History of Present Illness (HPI) for a follow-up psychiatric note is to structure it chronologically, focusing on changes in symptoms, medication effects, and functional status since the last visit.
Key Components of a Follow-Up Psychiatric HPI
Essential Elements to Include
- Begin with a brief statement identifying the patient and reason for follow-up (e.g., "Patient is a [age]-year-old [gender] returning for follow-up of [diagnosis]") 1
- Document changes in mood, anxiety, sleep patterns, and other psychiatric symptoms since the previous visit 2
- Include assessment of medication adherence, effectiveness, and any side effects experienced 3
- Note any changes in functional status, including activities of daily living and social/occupational functioning 2
- Document any suicidal ideation, self-harm behaviors, or other risk factors that require ongoing monitoring 3
Recommended Structure
- Organize information chronologically to improve clarity and clinical reasoning 4
- Use standardized assessment scales when appropriate to quantify symptom changes (e.g., PHQ-9 for depression, GAD-7 for anxiety) 2
- Include both subjective reports from the patient and objective observations 1
- Document any significant life events or stressors that may have impacted the patient's condition 2
Assessment Tools to Incorporate
- For depression follow-up, consider including PHQ-9 scores to track symptom severity over time 2
- For anxiety disorders, GAD-7 scores can help quantify anxiety levels (scores ≥15 indicate severe anxiety) 5
- The Hospital Anxiety and Depression Scale (HADS) is particularly useful as it excludes physical symptom items that might confound assessment in patients with comorbid medical conditions 2
- For elderly patients, consider using the Geriatric Depression Scale (GDS), which focuses on affective symptoms rather than somatic complaints that may be due to medical conditions 6
Special Considerations
For Elderly Patients
- Pay particular attention to somatic manifestations of depression such as sleep disturbances, which are common in elderly patients 6
- Document any cognitive changes that may be related to depression or anxiety 6
- Note any medication interactions or side effects, as elderly patients are more vulnerable to adverse effects 6
For Risk Assessment
- Always document current suicide risk assessment in follow-up notes, especially for patients with history of self-harm 3
- Include any changes in risk factors or protective factors since the previous visit 3
- Document safety planning discussions and interventions 3
Common Pitfalls to Avoid
- Avoid simply copying previous HPIs without updating relevant information 7
- Don't focus exclusively on medication effects while neglecting psychosocial factors 2
- Avoid using vague descriptors; instead, use specific examples of symptoms and behaviors 4
- Don't omit important negative findings (e.g., absence of suicidal ideation in a patient with depression) 3
Documentation Best Practices
- Use clear, concise language that accurately reflects the patient's current status 8
- Include direct quotes from the patient when they provide insight into their condition 1
- Document both improvements and deteriorations in symptoms 3
- Include information from collateral sources when available and relevant 2
- Ensure documentation reflects any education provided to the patient about their condition or medications 3
By following these guidelines, you can create comprehensive and clinically useful follow-up psychiatric HPIs that facilitate effective ongoing care and treatment planning.