What are the essential components and steps involved in conducting a comprehensive psychiatric evaluation?

Components of a Comprehensive Psychiatric Evaluation

A comprehensive psychiatric evaluation must include standardized sections for identifying information, chief complaint, history of present illness, psychiatric history, substance use, medical history, family history, personal/social history, mental status examination, risk assessment, impression, and treatment plan as recommended by the American Psychiatric Association. 1

Identifying Information

• Document patient demographics (name, age, gender, date of birth), date and time of evaluation, and sources of information (patient, family, medical records) 1

Chief Complaint and History of Present Illness

• Record the patient's own words regarding the presenting problem and circumstances leading to evaluation 1
• Conduct a psychiatric review of systems, including anxiety symptoms and panic attacks 2
• Assess sleep patterns and abnormalities, including sleep apnea 2
• Evaluate impulsivity and document chronology of symptom development 2, 1

Psychiatric History

• Identify past and current psychiatric diagnoses 2
• Document history of psychiatric hospitalizations and emergency department visits for psychiatric issues 2
• Review past psychiatric treatments (type, duration, doses), response to treatments, and adherence 2
• Assess prior psychotic or aggressive ideas, including thoughts of physical or sexual aggression or homicide 2
• Document prior suicidal ideas, plans, and attempts, including context, method, damage, lethality, and intent 2
• Record prior intentional self-injury without suicidal intent 2

Medical History

• Document allergies and drug sensitivities 1
• List current medications (prescribed, non-prescribed, supplements) 1
• Assess primary care relationship 1
• Document past/current medical illnesses and hospitalizations 1
• Evaluate cardiopulmonary status, endocrinological disease, and infectious diseases 1

Family History

• Assess psychiatric disorders in biological relatives 1
• Document history of suicidal behaviors in relatives, especially for patients with suicidal ideation 1

Social and Substance Use History

• Identify psychosocial stressors (financial, housing, legal, occupational, relationship problems) 1
• Assess trauma history 1
• Evaluate use of tobacco, alcohol, and other substances 1
• Document misuse of prescribed or over-the-counter medications 1
• Identify current or recent substance use disorders 1

Mental Status Examination

• Assess general appearance and nutritional status 2
• Evaluate coordination, gait, and involuntary movements or abnormalities of motor tone 2
• Assess sight and hearing 2
• Evaluate speech, including fluency and articulation 2
• Document mood, level of anxiety, thought content and process, and perception and cognition 2
• Assess for hopelessness 2

Risk Assessment

• Evaluate current suicidal ideas, suicide plans, and suicide attempts, including active or passive thoughts of suicide or death 2
• If suicidal ideas are present, assess:
  • Patient's intended course of action if symptoms worsen 2
  • Access to suicide methods including firearms 2
  • Patient's possible motivations for suicide 2
  • Reasons for living 2
  • Quality and strength of the therapeutic alliance 2
• Assess current aggressive or psychotic ideas, including thoughts of physical or sexual aggression or homicide 2
• Document an estimate of suicide risk, including factors influencing risk 2
• Document an estimated risk of aggressive behavior, including factors influencing risk 2

Assessment and Diagnosis

• Formulate DSM-5 diagnoses based on comprehensive assessment findings 1
• Include rationale for diagnoses that clearly connects assessment data to diagnostic criteria 1

Treatment Plan

• Document the rationale for treatment selection, including discussion of specific factors that influenced the treatment choice 2
• Include the rationale for clinical tests 2
• Ask the patient about treatment-related preferences 2
• Provide an explanation to the patient regarding differential diagnosis, risks of untreated illness, treatment options, and benefits and risks of treatment 2
• Collaborate with the patient about decisions pertinent to treatment 2
• Consider using quantitative measures of symptoms, level of functioning, and quality of life 2

Legal and Ethical Considerations

• Address any legal issues related to involuntary hospitalization if applicable 1
• Document capacity for informed consent 1
• Consider safety planning rather than no-suicide contracts for patients with suicidal ideation 1

Health Promotion/Disease Prevention

• Assess height, weight, and BMI as part of physical examination 1
• Record vital signs 1
• Evaluate for modifiable risk factors that may impact psychiatric and physical health 1

Documentation Requirements

• Ensure all sections are clearly documented with date and time 1
• Provide authentication by the evaluating clinician 1