What is the recommended approach for documenting an initial psychiatric assessment on a senior?

Documentation of Initial Psychiatric Assessment in Seniors

Follow the American Psychiatric Association's comprehensive evaluation framework, which includes standardized sections covering identifying information, chief complaint, history of present illness, psychiatric history, substance use, medical history, family history, personal/social history, mental status examination, physical examination, risk assessment, and treatment plan. 1, 2

Essential Header Information

• Document patient demographics (name, age, date of birth, gender), date and time of evaluation, and source of information (patient, family members, medical records, collateral contacts) 2
• Note whether an interpreter was needed or used, as this is a required assessment component 1

Chief Complaint and Reason for Admission

• Record the patient's own words describing the presenting problem 2
• Document the specific circumstances that led to the current evaluation or hospitalization 2

History of Present Illness

• Provide a chronological account of symptom development, including onset, duration, progression, and severity 2
• Conduct a psychiatric review of systems covering:
  • Mood symptoms (depression, elevated mood, irritability) 2
  • Anxiety symptoms and panic attacks 1, 2
  • Sleep patterns and abnormalities, including sleep apnea 1, 2
  • Psychotic symptoms (hallucinations, delusions) 2
  • Cognitive changes 2
  • Impulsivity 1, 2

Psychiatric History

• List all past and current psychiatric diagnoses 1, 2
• Document prior psychiatric hospitalizations and emergency department visits for psychiatric issues 1, 3
• Record prior suicidal ideas, plans, and attempts with specific details: context, method used, degree of damage, lethality of attempt, and intent 1, 3
• Assess prior intentional self-injury without suicidal intent 3
• Document prior psychotic or aggressive ideas, including thoughts of physical or sexual aggression or homicide 3
• Record prior aggressive behaviors such as homicide, domestic violence, workplace violence, or threats 1, 3
• List all past psychiatric treatments with type, duration, and doses where applicable 1, 3
• Document response to past psychiatric treatments and adherence to both pharmacological and non-pharmacological treatments 1, 3

Substance Use History

• Assess current and past use of tobacco, alcohol, marijuana, cocaine, heroin, hallucinogens, and other substances 1, 2
• Document any misuse of prescribed medications, over-the-counter medications, or supplements 1, 2
• Identify current or recent substance use disorders or changes in substance use patterns 1, 2

Medical History

This section is particularly critical in seniors due to high rates of medical comorbidity and polypharmacy. 4

• Document all allergies and drug sensitivities 1, 2
• List all current and recently discontinued medications (prescribed, non-prescribed, herbal supplements, vitamins) with doses and side effects 1, 2
• Assess whether the patient has an ongoing relationship with a primary care provider 1, 2
• Record past and current medical illnesses and related hospitalizations 1, 2
• Document relevant past or current treatments, including surgeries, procedures, and complementary/alternative treatments 1
• Assess past or current neurological or neurocognitive disorders or symptoms 1, 2
• Record history of physical trauma, including head injuries 1
• Document sexual and reproductive history 1
• Assess cardiopulmonary status 1, 2
• Record past or current endocrinological diseases 1, 2
• Document infectious disease history including sexually transmitted diseases, HIV, tuberculosis, hepatitis C, and locally endemic infections 1, 2
• Assess past or current conditions associated with significant pain and discomfort 1

Family History

• Document psychiatric disorders in biological relatives 2
• For patients with current suicidal ideas, specifically assess history of suicidal behaviors in biological relatives 1, 3
• For patients with current aggressive ideas, assess history of violent behaviors in biological relatives 1, 3

Personal and Social History

• Identify current psychosocial stressors: financial problems, housing instability, legal issues, occupational difficulties, interpersonal/relationship problems, lack of social support 1, 2
• Conduct a thorough review of the patient's trauma history 1, 2
• Document exposure to violence or aggressive behavior, including combat exposure or childhood abuse 1
• Record legal or disciplinary consequences of past aggressive behaviors 1
• Assess cultural factors related to the patient's social environment and cultural explanations of psychiatric illness 1

Physical Examination

• Measure and record height, weight, and body mass index (BMI) 1, 2
• Document vital signs (blood pressure, heart rate, respiratory rate, temperature) 1, 2
• Assess skin for stigmata of trauma, self-injury, or drug use 1
• Evaluate general appearance and nutritional status 1, 2
• Assess coordination and gait 1, 2
• Document involuntary movements or abnormalities of motor tone 1, 2
• Evaluate sight and hearing 1, 2

Mental Status Examination

• Describe appearance and behavior 2
• Assess speech, including fluency and articulation 1, 2
• Document mood (patient's subjective report) and affect (your objective observation) 1, 2
• Evaluate thought process (logical, tangential, circumstantial, flight of ideas, thought blocking) 2
• Assess thought content for delusions, obsessions, preoccupations 1
• Evaluate perception for hallucinations or illusions 1
• Assess cognition including orientation, attention, concentration, memory, and executive function 1, 2
• Document level of anxiety 1
• Assess for hopelessness 1

Risk Assessment

This is a critical section that must be thoroughly documented in every initial assessment. 2

• Evaluate current suicidal ideas, plans, and attempts, including both active and passive thoughts of suicide or death 1, 2
• If current suicidal ideas are present, specifically assess:
  • Patient's intended course of action if symptoms worsen 1
  • Access to suicide methods, particularly firearms 1
  • Possible motivations for suicide (attention-seeking, revenge, shame, escape from suffering) 1
• Assess current aggressive or psychotic ideas 2
• Provide a documented estimate of suicide risk with specific influencing factors (protective and risk factors) 2

Impression and Treatment Plan

• Develop a diagnostic formulation based on the comprehensive assessment using DSM criteria 2
• Create a treatment plan with clear rationale for each intervention 2
• Document the patient's treatment preferences and incorporate them when clinically appropriate 2
• Determine and document disposition plan (level of care needed: outpatient, intensive outpatient, partial hospitalization, inpatient) 2

Special Considerations for Geriatric Patients

The interaction between physical and psychological factors is exceptionally strong in elderly patients and must be carefully considered. 5

• Pay particular attention to polypharmacy, drug interactions, and medication side effects, as elderly patients typically take multiple medications 4
• Recognize that depression in seniors can lead to malnutrition or dehydration, which can induce various physical illnesses 5
• Be aware that physical illness in the elderly can induce depression due to psychological vulnerability 5
• Consider that cognitive impairment may affect the reliability of self-report and necessitate collateral information from family or caregivers 4

Documentation Requirements

• Clearly document all sections with date and time 2
• Provide authentication by the evaluating clinician with signature and credentials 2
• Recognize that the evaluation may require several meetings with the patient, family, or others before completion 3

Common Pitfalls to Avoid

• Neglecting to assess cultural factors can lead to misdiagnosis 3
• Omitting thorough documentation of all required domains may result in incomplete assessment 3
• Minimizing the importance of biological factors while focusing solely on psychological support is inadequate 5
• Failing to obtain collateral information from family or caregivers when cognitive impairment is present 4