What is the recommended template for completing a History and Physical (H&P) including the History of Present Illness (HPI) for a psychiatric patient?

Psychiatric History and Physical Examination Template

The psychiatric H&P should follow a structured format that prioritizes history of present illness with informant input, comprehensive psychiatric and substance use history, social history including trauma and psychosocial stressors, targeted physical examination of neurologic/cardiac/respiratory systems, and mental status examination—with laboratory testing reserved only for cases with specific clinical indicators rather than routine screening. 1, 2

History of Present Illness (HPI)

Opening Question and Symptom Characterization

• Begin with: "What is the main reason you are here to see me and what would you like to accomplish from the visit today?" 1
• Document who initiated the evaluation (patient versus family member), as cognitive or behavioral impairment often reduces patient insight 1
• Characterize the nature of presenting symptoms across all major domains, even if not volunteered by the patient 1
• Establish the temporal course: sequential order of onset, frequency, tempo, and nature of change over time 1
• Explore plausible relationships between events and symptoms, including potential triggers or contextual features 1

Psychiatric Review of Systems

The American Psychiatric Association mandates assessment of: 1

• Anxiety symptoms and panic attacks 1
• Sleep abnormalities, including sleep apnea 1
• Impulsivity 1
• Impact on activities of daily living (ADLs and IADLs) 1
• Mood and neuropsychiatric symptoms 1
• Sensory and motor function 1

Informant/Collateral Information

• Obtain reliable information from an informant (care partner) regarding changes in cognition, daily function, mood, and sensorimotor function, as informant reports provide added value beyond patient self-report, particularly when insight is impaired 1
• Collateral information is essential because patients frequently minimize symptoms or lack insight 2
• Use structured instruments for assessing each domain when possible 1

Psychiatric History

Past Psychiatric Diagnoses and Symptoms

Document: 1

• Past and current psychiatric diagnoses 1
• Prior psychotic or aggressive ideas, including thoughts of physical or sexual aggression or homicide 1
• Prior aggressive behaviors (homicide, domestic or workplace violence, other physically or sexually aggressive threats or acts) 1
• Prior suicidal ideas, suicide plans, and suicide attempts, including aborted or interrupted attempts, with details of context, method, damage, potential lethality, and intent 1
• Prior intentional self-injury without suicidal intent 1

Treatment History

Document: 1

• History of psychiatric hospitalization and emergency department visits for psychiatric issues 1
• Past psychiatric treatments (type, duration, doses where applicable) 1
• Response to past psychiatric treatments 1
• Adherence to past and current pharmacological and non-pharmacological treatments 1

Substance Use History

The American Psychiatric Association requires assessment of: 1

• Tobacco, alcohol, and other substance use (marijuana, cocaine, heroin, hallucinogens) 1
• Misuse of prescribed or over-the-counter medications or supplements 1
• Current or recent substance use disorder or change in use of alcohol or other substances 1
• Specific substances to assess include alcohol, amphetamines, barbiturates, benzodiazepines, and cocaine 2

Social History

Psychosocial Stressors and Risk Factors

The American Psychiatric Association recommends assessing: 3

• Financial problems 3
• Housing instability 3
• Legal issues 3
• School/occupational difficulties 3
• Interpersonal/relationship conflicts 3

These are established risk factors for suicidal ideation and aggressive behaviors and directly impact risk assessment and treatment adherence 3

Trauma History

• Complete review of trauma history, including exposure to violence or childhood abuse, as this fundamentally shapes symptom presentation and can mimic or complicate other psychiatric diagnoses 3

Cultural Factors

• Cultural factors related to the patient's social environment, including need for an interpreter and personal/cultural beliefs about psychiatric illness, as these influence symptom expression and treatment response 3

Medical History

Medication History

Document: 2

• All psychiatric medications, recent changes, and potential for withdrawal syndromes 2
• Recent medical illnesses or treatments, such as infections, metabolic disturbances, and endocrine disorders 2

Risk Factors for Cognitive Decline

Obtain information about individualized risk factors for cognitive decline, including potentially modifiable factors, as each person has their own profile of risk and resilience factors 1

Physical Examination

Vital Signs

• Vital signs assessment is crucial, as abnormal vital signs are among the most important predictors of underlying medical pathology with a pooled yield of 15.6% 2

Targeted Physical Examination

The physical examination must prioritize three systems where life-threatening conditions commonly present as psychiatric symptoms: 2

• Neurologic system 2
• Cardiac system 2
• Respiratory system 2

Physical examination has a pooled yield of 14.9% for detecting conditions requiring management changes, with no significant difference whether performed by psychiatrists or non-psychiatrists 2, 4

Mental Status Examination

Document the following core components systematically: 2

• Appearance and general behavior 2
• Motor activity 2
• Speech 2
• Mood and affect 2
• Thought process 2
• Thought content 2
• Perceptual disturbances 2
• Sensorium and cognition 2
• Insight and judgment 2

Laboratory and Radiographic Testing

Critical Principle: History and Physical Examination Guide Testing

Routine laboratory testing and brain imaging have extremely low yield (1.1%) and should NOT be performed routinely—laboratory and radiographic studies should be obtained ONLY when indicated by history and physical examination 2, 4

Indications for Targeted Testing

Order testing only when: 2

• Altered mental status 2
• Unexplained vital sign abnormalities 2
• New-onset or acute changes in psychiatric symptoms 2
• Abnormal neurologic findings on examination 2

Tests to Avoid Routinely

Do NOT order routinely: 2

• Routine urine toxicology screens 2
• Routine brain CT scans 2
• Routine laboratory panels 2

Common Pitfalls to Avoid

• Over-reliance on laboratory testing, as history and physical examination are far superior for detecting clinically significant conditions with yields of 15.6% and 14.9% respectively versus 1.1% for investigations 2, 4
• Ordering "routine" test batteries, which is costly, low-yield, and increases false-positive results 2
• Failing to obtain collateral information, as patients frequently minimize symptoms or lack insight 2
• Inadequate attention to vital signs, as abnormal vital signs are critical predictors of medical pathology 2
• Neglecting the physical examination, as it has a 14.9% yield for detecting conditions requiring management changes 2, 4
• Unnecessary radiation exposure, particularly in pediatric patients, due to routine brain CT scans 2