What are the essential components to include when writing psychiatric notes for an adult patient with a psychiatric condition?

Essential Components of Psychiatric Notes for Adult Patients

Psychiatric notes must systematically document comprehensive assessment domains including history of present illness, complete psychiatric and substance use history, medical history, family history, personal/social history, mental status examination, and risk assessment, as mandated by the American Psychiatric Association guidelines. 1

Core Documentation Requirements

Patient Presentation and History

• Document the reason for presentation and patient's stated goals and treatment preferences at the outset 2, 3
• Record the history of present illness with specific attention to onset, duration, severity, and functional impact of symptoms 2
• Include comprehensive psychiatric review of systems covering anxiety symptoms, panic attacks, sleep abnormalities (including sleep apnea), and impulsivity 2, 3

Psychiatric History Documentation

• Document all past and current psychiatric diagnoses with dates and diagnostic criteria met 2
• Record complete psychiatric treatment history including type, duration, and doses of all past treatments 2
• Document response to past psychiatric treatments and adherence patterns to both pharmacological and non-pharmacological interventions 2, 3
• Include history of psychiatric hospitalizations and emergency department visits for psychiatric issues 2

Substance Use Assessment

• Systematically evaluate tobacco, alcohol, marijuana, cocaine, heroin, and hallucinogen use 2, 3
• Document any misuse of prescribed or over-the-counter medications or supplements 2
• Assess for current or recent substance use disorders 2

Medical History and Physical Parameters

• Record all current and recent medications, including side effects and allergies or drug sensitivities 2
• Document past or current medical illnesses, hospitalizations, surgeries, and relevant treatments 2
• Measure and record vital signs, height, weight, and BMI as baseline physical parameters 4
• Examine skin for stigmata of trauma, self-injury, or drug use 4
• Evaluate for neurological or neurocognitive disorders and history of physical trauma, including head injuries 2

Mental Status Examination

• Systematically document general appearance and nutritional status, coordination, speech fluency and articulation, current mood state and anxiety level, thought content and process, perception and cognition 3, 4
• Assess and record orientation, memory, attention, and executive function 3
• Document level of hopelessness as this relates directly to suicide risk 3

Risk Assessment - Critical Safety Documentation

• Evaluate and document current suicidal ideas, suicide plans, and past suicide attempts with details of each attempt 2, 3, 4
• Document intentional self-injury without suicidal intent 2
• Assess access to suicide methods, possible motivations for suicide, and reasons for living 3
• For patients with current suicidal ideas, assess history of suicidal behaviors in biological relatives 2
• Evaluate current aggressive or psychotic ideas, including thoughts of physical or sexual aggression or homicide 2, 4
• Document prior aggressive behaviors (homicide, domestic violence, workplace violence) and legal or disciplinary consequences 2
• For patients with current aggressive ideas, assess history of violent behaviors in biological relatives 2
• Estimate and document the risk level with specific factors influencing that risk 3, 4

Psychosocial and Cultural Factors

• Document psychosocial stressors including financial, housing, legal, occupational, and interpersonal problems 2
• Review and record the patient's trauma history and exposure to violence or aggressive behavior 2
• Assess cultural factors related to the patient's social environment and need for an interpreter 2
• Document relationship with primary care provider 2
• Include sexual and reproductive history 2

Treatment Planning Documentation

• Create a documented, comprehensive, person-centered treatment plan that includes evidence-based nonpharmacological and pharmacological treatments 4
• Document the rationale for treatment selection, including discussion of specific factors that influenced the treatment choice 3, 4
• Incorporate standardized rating scales to identify and determine severity of symptoms and functional impairments that may be treatment targets 4

Authentication and Timing

• Document date and time of all assessment sections with authentication by the evaluating clinician 3
• Note that the evaluation may require several meetings with the patient, family, or others before completion 2

Critical Pitfalls to Avoid

• Never skip systematic symptom assessment even when patients drive the agenda, as patients may be reluctant to reveal emotional problems due to stigma, leading to missed diagnoses 4
• Never assume stable symptoms mean psychosocial assessment is unnecessary, as psychosocial factors predict healthcare utilization and relapse independent of symptom severity 4
• Never misinterpret mental status findings without considering education level, language barriers, or cultural factors 4
• Maintain careful attention to abnormal vital signs and complete neurologic examination to identify medical mimics of psychiatric conditions 3, 4
• Neglecting to consider cultural factors in the assessment process can lead to misdiagnosis 2

Information Gathering Methods

• Information should be obtained through face-to-face interview, review of medical records, physical examination, diagnostic testing, and history from collateral sources 1, 2
• The amount of time spent depends on the complexity of the problem, clinical setting, and patient's cooperation 2
• Use clinical judgment to tailor the psychiatric evaluation to each patient's unique circumstances, determining which questions are most important for initial assessment 1, 3, 4