What is the format for a follow-up psychiatry appointment assessment?

Follow-Up Psychiatry Appointment Assessment Format

For follow-up psychiatric appointments, conduct a focused update assessment that reviews interval changes in symptoms, treatment response, medication adherence, side effects, and current risk status, rather than repeating the comprehensive initial evaluation. 1, 2

Core Components of Follow-Up Assessment

Interval History Since Last Visit

• Document changes in psychiatric symptoms including mood, anxiety, psychosis, sleep patterns, and impulsivity since the previous appointment 1
• Assess treatment response to current medications and psychosocial interventions, noting both improvements and persistent symptoms 3, 4
• Review medication adherence and any missed doses, as non-compliance is a common reason for relapse and increased morbidity 3
• Identify new psychosocial stressors such as financial problems, housing instability, legal issues, occupational changes, or relationship difficulties 1

Medication Management Review

• Evaluate side effects systematically as they are a primary cause of medication non-compliance and treatment failure 3
• For antipsychotics specifically, monitor for extrapyramidal symptoms (dystonia, akathisia, parkinsonism), sedation, anticholinergic effects, and metabolic changes 3
• Document current medications including any changes in prescribed medications, over-the-counter drugs, or supplements since last visit 1
• Assess substance use including tobacco, alcohol, illicit drugs, and misuse of prescribed medications 1

Mental Status Examination (Focused)

• Appearance and behavior noting any changes from baseline 1
• Speech patterns including fluency and articulation 1
• Current mood and affect with particular attention to shifts from previous assessments 1
• Thought process and content especially for patients with psychotic disorders or thought disturbances 1

Risk Assessment (Critical at Every Visit)

• Current suicidal ideation, plans, and intent must be evaluated at each follow-up appointment 1
• Current aggressive or homicidal ideation particularly in patients with history of violence 1
• Document updated risk estimate with specific factors influencing current risk level 1
• Use safety planning rather than no-suicide contracts for patients with suicidal ideation 1

Measurement-Based Care

• Utilize validated rating scales to objectify symptom severity and track treatment outcomes over time 4
• This approach has been shown to improve patient outcomes compared to usual care and should be standard practice 4
• Examples include PHQ-9 for depression, GAD-7 for anxiety, or disorder-specific scales 3

Visit Frequency Guidelines

Acute Phase Management

• Weekly visits initially after starting new medications or during symptom exacerbations to establish rapport and ensure compliance 3
• More frequent contact (or hospitalization) may be needed during acute psychotic episodes or when there is danger to self or others 3

Maintenance Phase

• Monthly physician contact minimum once stabilized to adequately monitor symptom course, side effects, and compliance 3
• Frequency can decrease as clinically indicated, but should never extend beyond what is needed for adequate monitoring 3
• Integrate medication follow-up with ongoing psychosocial therapies to increase compliance and decrease relapse rates 3

Documentation Requirements

Essential Elements

• Date and time of evaluation 1
• Review of previous records confirming that prior assessments were examined 2
• Interval changes in symptoms, functioning, and treatment response 2
• Updated treatment plan with rationale for continuing or modifying current approach 1, 2
• Patient's treatment preferences and their input on the plan 1
• Authentication by evaluating clinician 1

Common Pitfalls to Avoid

• Do not perform unnecessary comprehensive re-evaluations when a focused update is appropriate, as this wastes resources and burdens patients 2
• Do not overlook updated risk assessments for suicide or violence at each visit, even in stable patients 2
• Do not assume medication adherence—directly ask about missed doses and barriers to compliance 3
• Do not ignore patient-reported side effects as these drive non-compliance and treatment failure 3
• Do not fail to document the rationale for treatment decisions and changes 1, 2