What steps are involved in conducting an initial psychiatric evaluation as a psychiatric nurse practitioner?

How to Conduct an Initial Psychiatric Evaluation as a Psychiatric Nurse Practitioner

The initial psychiatric evaluation should follow a systematic, comprehensive approach that includes detailed assessment of history of present illness, psychiatric and substance use history, medical history, family history, personal/social history, mental status examination, physical examination, risk assessment, and formulation of an impression with treatment plan. 1, 2

Core Structure of the Initial Evaluation

Identifying Information and Chief Complaint

• Document patient demographics (name, age, gender, date of birth), date and time of evaluation, and source of information (patient, family, medical records, collateral sources). 2
• Record the patient's chief complaint in their own words and document the circumstances leading to the evaluation. 2

History of Present Illness

• Conduct a comprehensive psychiatric review of systems, including specific assessment of anxiety symptoms and panic attacks. 1, 2
• Evaluate sleep patterns and abnormalities, specifically assessing for sleep apnea. 1, 2
• Assess impulsivity as a core component of the present illness evaluation. 1, 2
• Document the chronology of symptom development to understand the temporal progression of the illness. 2

Psychiatric History

This section requires detailed exploration of past psychiatric illness and treatment response:

• Identify all past and current psychiatric diagnoses. 1, 2
• Document prior psychotic or aggressive ideas, including thoughts of physical or sexual aggression or homicide. 1, 2
• Assess prior aggressive behaviors such as homicide, domestic or workplace violence, and other physically or sexually aggressive threats or acts. 1, 2
• Obtain detailed history of prior suicidal ideas, suicide plans, and suicide attempts, including attempts that were aborted or interrupted, with specific documentation of context, method, damage, potential lethality, and intent. 1, 2
• Document prior intentional self-injury where there was no suicidal intent. 1
• Review history of psychiatric hospitalization and emergency department visits for psychiatric issues. 1, 2
• Document all past psychiatric treatments including type, duration, and doses where applicable. 1
• Assess response to past psychiatric treatments and adherence to past and current pharmacological and non-pharmacological psychiatric treatments. 1

Substance Use History

• Assess the patient's use of tobacco, alcohol, and other substances including marijuana, cocaine, heroin, and hallucinogens. 1, 2
• Evaluate any misuse of prescribed or over-the-counter medications or supplements. 1, 2
• Identify current or recent substance use disorder or change in use of alcohol or other substances. 1, 2

Medical History

A thorough medical history is essential as medical conditions frequently contribute to psychiatric presentations:

• Document all allergies and drug sensitivities. 1, 2
• List all medications the patient is currently or recently taking, including prescribed and nonprescribed medications, herbal and nutritional supplements, and vitamins, along with side effects of these medications. 1, 2
• Determine whether the patient has an ongoing relationship with a primary care health professional. 1, 2
• Document past or current medical illnesses and related hospitalizations. 1, 2
• Review relevant past or current treatments, including surgeries, other procedures, or complementary and alternative medical treatments. 1
• Assess past or current neurological or neurocognitive disorders or symptoms. 1
• Document physical trauma, including head injuries. 1
• Obtain sexual and reproductive history. 1
• Evaluate cardiopulmonary status. 1, 2
• Assess past or current endocrinological disease. 1, 2
• Screen for past or current infectious diseases, including sexually transmitted diseases, HIV, tuberculosis, hepatitis C, and locally endemic infectious diseases such as Lyme disease. 1, 2
• Evaluate past or current symptoms or conditions associated with significant pain and discomfort. 1

Family History

• Assess psychiatric disorders in biological relatives. 1, 2
• For patients with current suicidal ideas, specifically assess history of suicidal behaviors in biological relatives. 1, 2
• For patients with current aggressive ideas, specifically assess history of violent behaviors in biological relatives. 1

Personal and Social History

• Identify presence of psychosocial stressors such as financial, housing, legal, school/occupational or interpersonal/relationship problems, lack of social support, and painful, disfiguring, or terminal medical illness. 1, 2
• Conduct a thorough review of the patient's trauma history. 1, 2
• Assess exposure to violence or aggressive behavior, including combat exposure or childhood abuse. 1, 2
• Document legal or disciplinary consequences of past aggressive behaviors. 1
• Evaluate cultural factors related to the patient's social environment and the patient's need for an interpreter. 1
• Assess personal/cultural beliefs and cultural explanations of psychiatric illness. 1

Physical and Mental Status Examination

Physical Examination Components

• Measure height, weight, and body mass index (BMI). 1, 2
• Record vital signs. 1, 2
• Examine skin, including any stigmata of trauma, self-injury, or drug use. 1
• Assess general appearance and nutritional status. 1, 2
• Evaluate coordination and gait. 1, 2
• Assess for involuntary movements or abnormalities of motor tone. 1, 2
• Test sight and hearing. 1, 2

Mental Status Examination

The mental status examination is essential for distinguishing between mood disorders, thought disorders, and cognitive impairment: 3

• Assess speech, including fluency and articulation. 1, 2
• Evaluate mood, level of anxiety, thought content and process, and perception and cognition. 1, 2
• Assess for hopelessness. 1
• Document appearance and behavior. 2
• Evaluate thought process (logical, tangential, circumstantial, etc.). 2

Critical Risk Assessment

Suicide Risk Assessment

When current suicidal ideas are present, conduct a detailed assessment including:

• Current suicidal ideas, suicide plans, and suicide attempts, including active or passive thoughts of suicide or death. 1, 2
• Patient's intended course of action if current symptoms worsen. 1
• Access to suicide methods including firearms. 1
• Patient's possible motivations for suicide (e.g., attention or reaction from others, revenge, shame, humiliation, delusional guilt, command hallucinations). 1
• Reasons for living (e.g., sense of responsibility to children or others, religious beliefs). 1
• Quality and strength of the therapeutic alliance. 1

Aggression Risk Assessment

When current aggressive ideas are present, assess:

• Current aggressive or psychotic ideas, including thoughts of physical or sexual aggression or homicide. 1, 2
• Specific assessment of triggers and response to interventions. 2

Impression and Plan

Documentation Requirements

• Document an estimate of the patient's suicide risk, including factors influencing risk. 1, 2
• Document an estimated risk of aggressive behavior (including homicide), including factors influencing risk. 1, 2
• Provide a diagnostic formulation based on the comprehensive assessment. 2
• Document the rationale for treatment selection, including discussion of the specific factors that influenced the treatment choice. 1, 2
• Document the rationale for clinical tests. 1

Patient Engagement and Shared Decision-Making

• Ask the patient about treatment-related preferences. 1, 2
• Provide an explanation to the patient of the differential diagnosis, risks of untreated illness, treatment options, and benefits and risks of treatment. 1
• Collaborate with the patient about decisions pertinent to treatment. 1, 2
• Consider using quantitative measures of symptoms, level of functioning, and quality of life. 1

Important Clinical Considerations

The evaluation may require several meetings with the patient, family, or others before it can be completed, and the amount of time spent depends on the complexity of the problem, the clinical setting, and the patient's ability and willingness to cooperate with the assessment. 1

Assessment is not limited to direct examination of the patient but includes review of medical records, physical examination, diagnostic testing, and history-taking from collateral sources. 1

All sections should be clearly documented with date and time, with authentication by the evaluating clinician. 2