What should be included in documentation for a psych assessment?

Documentation for Psychiatric Assessment

A comprehensive psychiatric assessment must include standardized sections covering identifying information, chief complaint, history of present illness with psychiatric review of systems, complete psychiatric and substance use histories, medical and family histories, personal/social history with trauma assessment, physical examination with vital signs, detailed mental status examination, thorough risk assessment for suicide and violence, and a documented impression with treatment plan and rationale. 1, 2

Essential Documentation Sections

Patient Identification and Context

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

History of Present Illness

• Chronological development of current symptoms including onset, duration, severity, and progression 2
• Psychiatric review of systems covering mood symptoms, anxiety and panic attacks, psychotic symptoms, sleep patterns and abnormalities, impulsivity, and cognitive changes 1, 2

Psychiatric History

• All past and current psychiatric diagnoses with dates of onset 2
• Prior psychiatric treatments including medications (names, duration, doses), psychotherapy, hospitalizations, and ECT 1
• Response to past treatments and adherence patterns 1
• Prior suicidal ideation, plans, and attempts with detailed context including method, medical damage, lethality, and intent 1, 2
• Prior aggressive or psychotic ideas and behaviors including homicide attempts, domestic violence, and threats 2

Substance Use History

• Current and past use of tobacco, alcohol, marijuana, cocaine, heroin, hallucinogens, and other substances 1, 2
• Misuse of prescribed medications, over-the-counter drugs, or supplements 1, 2
• Current or recent substance use disorders and changes in substance use patterns 1, 2

Medical History

• Allergies and drug sensitivities 1, 2
• All current medications (prescribed, non-prescribed, herbal supplements, vitamins) with side effects 1, 2
• Relationship with primary care provider 1, 2
• Past and current medical illnesses including hospitalizations, surgeries, and procedures 1, 2
• Neurological or neurocognitive disorders, head injuries, and physical trauma 1
• Sexual and reproductive history 1
• Cardiopulmonary status, endocrinological disease, and infectious diseases (STDs, HIV, tuberculosis, hepatitis C) 1, 2

Family History

• Psychiatric disorders in biological relatives 2
• History of suicidal behaviors in relatives (particularly important for patients with current suicidal ideation) 1, 2
• History of violent behaviors in relatives (particularly for patients with current aggressive ideas) 1

Personal and Social History

• Psychosocial stressors including financial, housing, legal, occupational, and relationship problems 1, 2
• Complete trauma history with exposure to violence, aggressive behavior, combat exposure, or childhood abuse 1, 2
• Legal or disciplinary consequences of past aggressive behaviors 1
• Cultural factors related to social environment and need for interpreter 1

Physical Examination

• Height, weight, and body mass index (BMI) 1, 2
• Vital signs 1, 2
• Skin examination for stigmata of trauma, self-injury, or drug use 1
• General appearance and nutritional status 1, 2

Mental Status Examination

• Appearance and behavior 2
• Coordination and gait 1
• Involuntary movements or abnormalities of motor tone 1
• Sight and hearing 1
• Speech including fluency and articulation 1, 2
• Mood, level of anxiety, affect 1, 2
• Thought process (logical, tangential, circumstantial, flight of ideas) 2
• Thought content and perception 1
• Cognition including orientation, memory, attention, and executive function 1
• Hopelessness 1

Risk Assessment (Critical Component)

For suicidal ideation, document:

• Current suicidal ideas, plans, and attempts including active or passive thoughts of suicide or death 1, 2
• Patient's intended course of action if symptoms worsen 1
• Access to suicide methods, specifically firearms 1
• Possible motivations for suicide (attention-seeking, revenge, shame, humiliation, delusional guilt, command hallucinations) 1
• Reasons for living (responsibility to children, religious beliefs) 1
• Quality and strength of therapeutic alliance 1

For aggressive ideation, document:

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

Impression and Plan

• Documented estimate of suicide risk with specific influencing factors 1, 2
• Documented estimate of aggressive behavior risk (including homicide) with influencing factors 1
• Differential diagnosis 1
• Explanation to patient of differential diagnosis, risks of untreated illness, treatment options, and benefits/risks of treatment 1
• Patient's treatment-related preferences 1, 2
• Rationale for treatment selection with discussion of specific factors influencing treatment choice 1, 2
• Rationale for any clinical tests ordered 1
• Collaboration with patient about treatment decisions 1

Additional Documentation Considerations

Quantitative Measures

• Consider using validated rating scales to objectify symptom severity (e.g., PHQ-9 for depression, GAD-7 for anxiety) 3

Authentication Requirements

• All sections must be clearly documented with date and time 2
• Authentication by the evaluating clinician is required 2

Common Pitfalls to Avoid

The most critical error is inadequate risk assessment documentation. 1 Failing to document specific suicide risk factors, access to means, and protective factors can have serious medicolegal and clinical consequences. Always document the specific factors that influenced your risk estimate rather than simply stating "low," "medium," or "high" risk.

Another common pitfall is incomplete substance use assessment. 1 Clinicians often focus only on alcohol and illicit drugs while missing prescription medication misuse and over-the-counter supplement use, which can significantly impact psychiatric presentation and treatment.