What components should be included in the Core Assessment Framework for every initial psychiatric evaluation performed by a healthcare provider?

Core Assessment Framework for Initial Psychiatric Evaluation

Every initial psychiatric evaluation must include a comprehensive assessment of suicide and violence risk, mental status examination, substance use history, and collaborative treatment planning with documented patient preferences. 1

Essential Assessment Domains

Patient Safety and Risk Assessment (Highest Priority)

Current suicidal ideation must be assessed at every initial evaluation, including: 1

• Active or passive thoughts of suicide or death
• Specific suicide plans and access to lethal means (especially firearms)
• Past suicide attempts with details on method, lethality, and intent
• Patient's intended course of action if symptoms worsen
• Motivations for suicide (attention-seeking, revenge, shame, delusional guilt, command hallucinations)
• Protective factors including reasons for living, sense of responsibility to others, and religious beliefs 1

Current aggressive or homicidal ideation requires systematic evaluation, particularly: 1

• Thoughts of physical or sexual aggression toward specific individuals
• History of violent behaviors including domestic violence and threats
• Access to weapons
• Psychotic symptoms that may drive violence 1

Document a formal estimate of suicide risk and aggressive behavior risk with specific influencing factors in every evaluation. 1

Mental Status Examination

The following components are mandatory: 1

• General appearance and nutritional status - observe for self-neglect, weight changes, hygiene
• Coordination and gait - assess for neurological abnormalities or medication side effects
• Involuntary movements or abnormalities of motor tone - screen for extrapyramidal symptoms or tardive dyskinesia
• Sight and hearing - identify sensory deficits that may affect communication
• Speech including fluency and articulation - evaluate for thought disorder, neurological conditions, or intoxication
• Mood, level of anxiety, thought content and process, perception and cognition - comprehensive assessment of all psychiatric domains
• Hopelessness - critical predictor of suicide risk 1

Psychiatric and Substance Use History

Identify all past and current psychiatric diagnoses, including: 1

• Previous psychiatric hospitalizations and emergency visits
• Response to past treatments (medications and psychotherapy)
• Treatment adherence patterns
• Prior psychotic or aggressive episodes 1

Substance use assessment must cover: 1

• Tobacco, alcohol, and illicit drug use with quantities and frequency
• Misuse of prescribed or over-the-counter medications
• Current or recent substance use disorders
• Recent changes in substance use patterns 1

Medical History and Physical Assessment

Document the following medical factors: 1

• Allergies and drug sensitivities
• All current medications (prescribed, over-the-counter, supplements)
• Past and current medical illnesses that could affect psychiatric diagnosis
• Cardiopulmonary, endocrinological, and infectious disease status
• Relationship with primary care provider 1

Family and Social Context

Assess family psychiatric history, particularly: 1

• Psychiatric disorders in biological relatives
• Family history of suicidal or violent behaviors (especially relevant when patient has similar ideation) 1

Evaluate psychosocial stressors and trauma: 1

• Financial, housing, legal, occupational, and relationship problems
• History of trauma or exposure to violence
• Cultural factors affecting presentation and treatment
• Need for interpreter services 1

Patient Collaboration and Treatment Planning

The initial evaluation must include shared decision-making components: 1

• Ask the patient directly about treatment-related preferences
• Explain the differential diagnosis clearly
• Discuss risks of untreated illness
• Review all treatment options with their benefits and risks
• Collaborate on decisions pertinent to treatment 1

Document the rationale for treatment selection, including specific factors that influenced the treatment choice. 1

Quantitative Assessment Tools

Consider using validated rating scales to measure symptom severity, functional level, and quality of life, though this is a suggestion rather than requirement. 1 This provides objective tracking of treatment response over time.

Documentation Requirements

Every initial evaluation must document: 1

• Estimated suicide risk with influencing factors
• Estimated risk of aggressive behavior with influencing factors (suggested)
• Treatment rationale with specific justification
• Rationale for any clinical tests ordered 1

Critical Caveats

Clinical judgment supersedes rigid adherence to these guidelines. 1 The evaluation must be tailored to:

• The specific clinical context and urgency of the situation
• Individual patient circumstances and presentation
• Available time and resources
• Patient's ability to participate in the evaluation 1

Some assessment areas may need to be postponed to subsequent visits depending on patient acuity, cooperation, or time constraints. 1

These guidelines are not a "standard of care" and omitting specific elements does not constitute malpractice, as clinical circumstances vary. 1 However, the core safety assessments (suicide and violence risk) should rarely if ever be deferred.

The evaluation extends beyond direct patient examination to include collateral information from family, prior records, and other treating clinicians. 1