Comprehensive Psychiatric Evaluation Guideline
Core Assessment Framework
A comprehensive psychiatric evaluation must systematically assess eight essential domains: presenting symptoms and psychiatric history, substance use, complete medical history, family psychiatric and suicide history, psychosocial stressors and trauma exposure, physical and mental status examination, suicide and violence risk assessment, and treatment planning with patient preferences. 1
1. Chief Complaint and History of Present Illness
Initial Documentation
- Record the patient's exact words describing their presenting problem 2
- Document circumstances leading to the current evaluation 2
- Establish chronology of symptom development with specific onset dates and progression 1, 2
Psychiatric Review of Systems
Systematically assess for:
- Mood symptoms: Depressed mood, anhedonia, irritability, elevated mood, mood lability 1, 2
- Anxiety symptoms: Generalized worry, panic attacks with specific triggers and frequency 1, 2
- Sleep disturbances: Insomnia, hypersomnia, sleep apnea symptoms 2
- Psychotic symptoms: Hallucinations (auditory, visual, tactile), delusions, paranoia 1, 2
- Cognitive symptoms: Memory problems, concentration difficulties, confusion 1
- Behavioral symptoms: Impulsivity, agitation, psychomotor changes 2
2. Psychiatric History
Past Diagnoses and Treatment
- Document all previous psychiatric diagnoses with dates of onset 1, 2
- List all past psychiatric treatments including:
- Assess adherence to past and current treatments 1
Suicide History
- Prior suicidal ideation: Frequency, intensity, duration 1, 2
- Prior suicide attempts: Document each attempt with context, method used, medical damage sustained, perceived lethality, and intent to die 1, 2
- Self-harm behaviors: Non-suicidal self-injury patterns 1
Violence History
- Prior aggressive or homicidal ideation 2
- History of violent behaviors including domestic violence, assault, threats 1, 2
- Legal or disciplinary consequences of aggressive behaviors 1
3. Substance Use History
Comprehensive Substance Assessment
- Tobacco use: Type, quantity, duration 1
- Alcohol use: Quantity, frequency, pattern of use, withdrawal symptoms 1
- Illicit substances: Marijuana, cocaine, heroin, hallucinogens, methamphetamine - document frequency and route 1
- Prescription medication misuse: Opioids, benzodiazepines, stimulants 1
- Over-the-counter medications and supplements: Specific products and doses 1
- Current or recent substance use disorder: Assess for DSM criteria 1
- Recent changes in substance use patterns: Increases, decreases, or new substances 1
4. Medical History
Current Medical Status
- All current medications: Prescribed, over-the-counter, herbal supplements, vitamins with doses 1
- Medication allergies and sensitivities: Specific reactions experienced 1
- Side effects from current medications: Document all reported adverse effects 1
- Primary care relationship: Whether patient has ongoing primary care physician 1
Past Medical History
- Past and current medical illnesses with dates of diagnosis 1
- Hospitalizations and surgeries with dates 1
- Neurological conditions: Seizures, stroke, traumatic brain injury, movement disorders 1
- Head injuries: Severity, loss of consciousness, sequelae 1
- Cardiopulmonary status: Heart disease, arrhythmias, hypertension, respiratory conditions 1
- Endocrine disorders: Thyroid disease, diabetes, adrenal disorders 1
- Infectious diseases: HIV, hepatitis C, tuberculosis, sexually transmitted infections, Lyme disease 1
- Chronic pain conditions: Location, severity, impact on function 1
- Sexual and reproductive history: Pregnancy history, sexual dysfunction, contraception 1
Pre-Medication Baseline (When Pharmacotherapy Planned)
- Height, weight, and BMI 1, 2
- Vital signs including blood pressure and heart rate 1, 2
- Targeted testing based on medication risks: Lipid panel before antipsychotics, ECG for cardiac history before stimulants 1
- Personal or family history of conditions increasing medication risks (structural cardiac abnormalities, malignant arrhythmias, sudden cardiac death) 1
5. Family History
Psychiatric Family History
- Psychiatric disorders in biological relatives with specific diagnoses 1, 2
- For patients with suicidal ideation: History of suicide or suicide attempts in biological relatives 1, 2
- For patients with aggressive ideation: History of violent behaviors in biological relatives 1
- Family history of substance use disorders 2
- Family history of medical conditions affecting medication selection (cardiac disease, metabolic disorders) 1
6. Personal and Social History
Psychosocial Assessment
- Current psychosocial stressors: 1, 2
- Financial problems
- Housing instability
- Legal issues
- School or occupational difficulties
- Interpersonal or relationship conflicts
- Lack of social support
- Terminal or disfiguring medical illness
Trauma and Violence Exposure
- Comprehensive trauma history: Types of trauma, age at occurrence, duration 1, 2
- Exposure to violence: Witnessing violence, being victim of violence 1
- Combat exposure: Military service and combat-related trauma 1
- Childhood abuse: Physical, sexual, emotional abuse or neglect 1
Cultural Factors
- Cultural factors related to social environment 1
- Need for interpreter services 1
- Personal and cultural beliefs about psychiatric illness 1
- Cultural explanations for symptoms 1
7. Physical Examination
Vital Measurements
Physical Findings
- General appearance and nutritional status: Grooming, hygiene, apparent age vs. stated age 1, 2
- Skin examination: Stigmata of trauma, self-injury scars (linear cuts, burns), injection sites, track marks 1
- Neurological examination: 1, 2
- Coordination and gait
- Involuntary movements (tremor, tardive dyskinesia, akathisia)
- Abnormalities of motor tone (rigidity, dystonia)
- Sensory function: Vision and hearing assessment 1
8. Mental Status Examination
Appearance and Behavior
- Level of consciousness and alertness 2
- Grooming, hygiene, and dress 2
- Eye contact and rapport 2
- Psychomotor activity (agitation, retardation, restlessness) 2
Speech
Mood and Affect
- Mood: Patient's subjective report in their own words 1, 2
- Affect: Observed emotional expression - range, intensity, appropriateness, stability 2
- Hopelessness: Specifically assess for feelings of hopelessness 1
- Anxiety level: Observable signs of anxiety 1
Thought Process
- Logical vs. illogical 2
- Linear vs. tangential, circumstantial, or loose associations 2
- Flight of ideas or thought blocking 2
Thought Content
- Suicidal ideation: Active vs. passive thoughts of death or suicide 1, 2
- Homicidal or aggressive ideation: Thoughts of harming others 2
- Delusions: Persecutory, grandiose, referential, somatic 1, 2
- Obsessions or preoccupations: Intrusive thoughts 2
Perceptual Disturbances
- Hallucinations: Auditory, visual, tactile, olfactory, gustatory 1, 2
- Command hallucinations and patient's response 2
- Illusions or depersonalization/derealization 2
Cognition and Sensorium
- Orientation: Person, place, time, situation 2
- Attention and concentration: Ability to focus and sustain attention 1
- Memory: Immediate recall, short-term, long-term 2
- Executive function: Abstract thinking, judgment, problem-solving 2
Insight and Judgment
- Patient's understanding of their illness 2
- Recognition of need for treatment 2
- Decision-making capacity 2
9. Risk Assessment
Suicide Risk Evaluation
For ALL patients with current suicidal ideation, assess: 1, 2
- Current suicidal thoughts: Frequency, intensity, duration 1
- Suicide plans: Specific method, timeline, preparatory behaviors 1
- Intent: Desire to die vs. ambivalence 1
- Access to lethal means: Firearms, medications, other methods 1
- Protective factors: Reasons for living, social support, future orientation 1
- Patient's intended course of action if symptoms worsen: Specific safety plan 1
- Motivations for suicide: Escape from pain, revenge, attention-seeking, psychosis 1
Violence Risk Evaluation
For patients with aggressive or homicidal ideation, assess: 1, 2
- Current aggressive thoughts and targets 2
- History of violent behaviors 1, 2
- Triggers for aggression 2
- Access to weapons 1
- Substance use patterns 1
Risk Documentation
- Provide documented estimate of suicide risk level (low, moderate, high) 2
- List specific factors influencing risk assessment 2
- Use safety planning rather than no-suicide contracts 2
10. Diagnostic Formulation and Treatment Plan
Diagnostic Assessment
- Primary psychiatric diagnosis based on DSM criteria 2
- Differential diagnoses considered 2
- Medical conditions contributing to psychiatric presentation 2
- Substance-induced vs. primary psychiatric disorder 2
Treatment Plan Development
- Pharmacological interventions: Specific medications with rationale, target symptoms, and monitoring plan 1, 2
- Psychosocial interventions: Specific therapy modalities indicated 1
- Level of care determination: Outpatient, intensive outpatient, partial hospitalization, inpatient 2
- Patient's treatment preferences: Document patient's goals and preferred approaches 1, 2
- Rationale for treatment selection: Link interventions to specific symptoms and evidence base 2
Monitoring Plan
- Frequency of follow-up visits 1
- Specific symptoms or side effects to monitor 1
- Laboratory monitoring if indicated 1
- Safety monitoring for suicide or violence risk 1
Special Considerations for Pediatric Patients
Additional Assessment Components
- Interviews with both child and parents separately and together 1
- Balance confidentiality needs of child and parents 1
- Review of previous treatment records to avoid repeating ineffective interventions 1
- Assessment of developmental history and school functioning 1
Pre-Medication Evaluation
- Medical history including structural cardiac abnormalities before stimulants 1
- Family history of malignant arrhythmias or sudden cardiac death before antipsychotics 1
- Baseline height and weight for stimulants 1
- Baseline height, weight, and lipid testing for antipsychotics 1
Documentation Requirements
Essential Elements
- Date and time of evaluation 2
- Source of information (patient, family, records, collateral contacts) 2
- All assessment sections clearly documented 2
- Authentication by evaluating clinician 2
For Patient Transfers Within Same System
When comprehensive records are accessible, perform focused update rather than duplicative evaluation: 3
- Review existing comprehensive assessment documentation 3
- Document changes in symptoms or mental status since last evaluation 3
- Update current suicidal or aggressive ideation 3
- Assess response to current treatment 3
- Identify new psychosocial stressors 3
- Perform full comprehensive evaluation if: Significant change in condition, new psychiatric symptoms not previously evaluated, new medical symptoms affecting psychiatric presentation, or inadequate previous documentation 3
Common Pitfalls to Avoid
- Inadequate suicide risk assessment: Always assess access to lethal means, especially firearms, for any patient with suicidal ideation 1
- Missing substance-induced presentations: Thoroughly assess all substance use before attributing symptoms to primary psychiatric disorder 1
- Overlooking medical causes: Cardiac, endocrine, and infectious diseases can present with psychiatric symptoms 1, 4
- Insufficient trauma history: Many patients will not spontaneously report trauma; direct questioning is necessary 1
- Inadequate medication history: Document specific doses and duration, not just medication names 1
- Failing to assess treatment adherence: Past non-adherence predicts future adherence problems 1
- Using no-suicide contracts instead of safety planning: Safety planning is evidence-based; contracts are not 2
- Duplicating comprehensive evaluations unnecessarily: For transfers within same system with accessible records, focused updates are appropriate 3
- Inadequate pre-medication screening: Failing to identify cardiac risk factors before stimulants or metabolic risk factors before antipsychotics 1