What should be included in an HPI for a psych follow-up?

History of Present Illness for Psychiatric Follow-Up

For a psychiatric follow-up visit, the HPI should focus on interval changes in symptoms, treatment response, medication adherence, side effects, and current risk assessment rather than repeating the comprehensive initial evaluation. 1

Core Components to Document

Symptom Changes Since Last Visit

• Document specific changes in target psychiatric symptoms including mood, anxiety, psychosis, sleep patterns, and impulsivity since the previous appointment 2, 1
• Assess both improvements and persistent symptoms in response to current medications and psychosocial interventions 1
• Use validated rating scales (PHQ-9 for depression, GAD-7 for anxiety) to objectify symptom severity and track treatment outcomes over time 1

Medication Management Review

• Review medication adherence systematically, including any missed doses, as non-compliance is a common reason for relapse and increased morbidity 1
• Document current medications and any changes in prescribed medications, over-the-counter drugs, or supplements since the last visit 1
• Evaluate side effects systematically, as they are a primary cause of medication non-compliance and treatment failure 1
• For patients on antipsychotics, specifically monitor for extrapyramidal symptoms, sedation, anticholinergic effects, and metabolic changes 1

Risk Assessment at Every Visit

• Evaluate current suicidal ideation, plans, and intent at each follow-up appointment 1
• Assess current aggressive or homicidal ideation, particularly in patients with a history of violence 1
• Ask specific screening questions: "Have you been feeling sad, angry, or less interested in things than usual?" and "Had thoughts of harming yourself or ending your life?" 2

Functional Status and Psychosocial Factors

• Assess changes in daily functioning including work, school, relationships, and self-care abilities 2
• Document new psychosocial stressors (financial, housing, legal, occupational, relationship problems) that have emerged since the last visit 2

Documentation Structure

Opening Statement

• Begin with a brief statement of the patient's current status: "Patient returns for follow-up of [diagnosis], currently on [medications]" 1

Interval History

• Describe the time period since last visit and overall trajectory (improved, stable, worsened) 1
• Note any significant events, stressors, or changes in circumstances 2

Symptom Review

• Address each target symptom systematically with quantifiable measures when possible 1
• Include both subjective patient report and objective observations 3

Treatment Response and Adherence

• Document medication adherence patterns and reasons for any non-adherence 1
• Note response to current treatment regimen, including both benefits and limitations 1

Side Effects

• Systematically review for medication side effects, as this directly impacts adherence and treatment success 1

Safety Assessment

• Always include current risk assessment for self-harm and harm to others 1

Common Pitfalls to Avoid

• Do not repeat the comprehensive initial evaluation when records are accessible within the same healthcare system 4
• Avoid vague statements like "doing well" or "no changes"—quantify symptom severity and functional status 1
• Do not skip risk assessment even in stable patients, as suicidality should be evaluated at every encounter 1
• Failing to document medication adherence patterns leads to misinterpretation of treatment failure versus non-compliance 1
• Do not rely solely on patient report—incorporate collateral information from family when available and observe mental status throughout the encounter 2, 3