What questions should be answered during psychiatric outpatient intake for a patient with potential psychiatric diagnoses, hospitalizations, or treatments, including assessment of current symptoms, mental status, substance use, and medication history?

Psychiatric Outpatient Intake Assessment

A comprehensive psychiatric outpatient intake must systematically evaluate psychiatric symptoms, substance use, medical conditions, mental status, treatment history, and risk factors to identify psychiatric disorders and guide treatment planning. 1

Core Psychiatric Symptom Assessment

The psychiatric review of systems should systematically evaluate:

• Anxiety symptoms and panic attacks, including frequency, triggers, and severity 1
• Sleep abnormalities, including insomnia, hypersomnia, and sleep quality 1
• Impulsivity patterns that may indicate mood disorders or personality pathology 1
• Current and past psychiatric diagnoses, including age of onset and course 1
• Prior psychotic symptoms, including hallucinations, delusions, or disorganized thinking 1
• Aggressive ideation or behavior, including homicidal thoughts and history of violence 1
• Suicidal ideation, plans, and attempts, including current thoughts, past attempts, methods used, and lethality 1

Complete Treatment History Documentation

Document the entire psychiatric treatment trajectory:

• All psychiatric hospitalizations, including dates, duration, and reasons for admission 1
• Past psychiatric treatments, both pharmacological and psychotherapeutic 1
• Response to past treatments, noting which interventions were effective or ineffective 1
• Adherence patterns to previous medications and therapy, as non-compliance is a primary cause of treatment failure 2

Comprehensive Substance Use Evaluation

Systematically assess all substance use categories:

• Tobacco use, including amount and duration 1
• Alcohol consumption, including frequency, quantity, and patterns of use 1
• Marijuana, cocaine, heroin, and hallucinogen use 1
• Misuse of prescribed medications, over-the-counter drugs, and supplements 1

This is critical because substance use can mimic or exacerbate psychiatric symptoms and significantly impacts treatment planning.

Medical Mimic Identification

Conduct a targeted medical history and physical examination to identify medical conditions that could cause or exacerbate psychiatric symptoms, as 46% of psychiatric patients may have medical illnesses directly contributing to their presentation. 3

Evaluate specifically for:

• Cardiopulmonary status, including chest pain, dyspnea, or palpitations 1
• Endocrinological disease, particularly thyroid disorders which commonly present with psychiatric symptoms 1
• Infectious diseases that may affect mental status 1
• Abnormal vital signs (blood pressure, heart rate, temperature) that warrant further medical workup 1

A focused medical assessment based on history and physical examination is superior to routine laboratory testing in patients with normal vital signs and non-contributory examinations. 3

Mental Status Examination

Systematically document:

• General appearance and nutritional status, including grooming, hygiene, and body habitus 1
• Speech fluency and articulation, noting rate, volume, and coherence 1
• Current mood state and anxiety level, using both patient's subjective report and objective observation 1
• Hopelessness, which is a critical predictor of suicide risk 1
• Thought content and process, including presence of suicidal or homicidal ideation, delusions, obsessions 1
• Perception and cognition, assessing for hallucinations and cognitive deficits 1
• Orientation, memory, attention, and executive function to identify cognitive impairment 1

Comprehensive Risk Assessment

Evaluate and document current suicidal ideas, plans, and attempts at every encounter, as this is essential for determining level of care and preventing mortality. 1

Specific elements include:

• Current suicidal ideation, including passive thoughts of death versus active plans 1
• Access to suicide methods, particularly firearms and medications 1
• Possible motivations for suicide, including hopelessness, psychosis, or impulsivity 1
• Reasons for living, which are protective factors 1
• Risk of aggressive behavior, including homicidal ideation and history of violence 1
• Factors influencing risk, such as substance use, social support, and psychiatric symptoms 1

Documentation Requirements

All assessment components must be properly documented:

• Date and time of evaluation 1
• All assessment sections with appropriate detail 1
• Rationale for treatment selection and clinical decision-making 1
• Authentication by the evaluating clinician 1

Critical Clinical Judgment Considerations

Clinical judgment is essential in tailoring the psychiatric evaluation to each patient's unique circumstances and determining which questions are most important for initial assessment. 3, 1 Not all elements need to be completed in the first visit, and some may be postponed to subsequent appointments based on clinical acuity and patient cooperation. 3

Common pitfall: Failing to obtain collateral information from family members or other providers, which is often essential when patients minimize symptoms or lack insight into their condition. 3