What are the essential elements of a comprehensive assessment section in a psychiatric note for both intake and follow-up clinical impressions, considering factors such as mental status, medical history, current medications, and patient demographics, including age, gender, and past psychiatric diagnoses?

Comprehensive Psychiatric Assessment Documentation

Initial Intake Assessment Elements

For intake evaluations, document a complete psychiatric assessment that includes identifying information, chief complaint, comprehensive history of present illness with psychiatric review of systems, full psychiatric and substance use history, medical history, family history, personal/social history, mental status examination, physical examination findings, risk assessment, and diagnostic formulation with treatment plan. 1, 2

Identifying Information and Source Documentation

• Patient demographics: name, age, gender, date of birth 1
• Date and time of evaluation 1
• Source of information (patient, family members, medical records, collateral contacts) 1

Chief Complaint/Reason for Admission

• Patient's own words describing the presenting problem 1
• Specific circumstances that led to seeking psychiatric evaluation or hospitalization 1

History of Present Illness

• Chronological development of current symptoms from onset to presentation 1
• Psychiatric review of systems including:
  • Depressive symptoms (anhedonia, guilt, worthlessness, concentration problems) 2
  • Anxiety symptoms and panic attacks 1, 2
  • Psychotic symptoms (hallucinations, delusions, disorganized thinking) 2
  • Manic or hypomanic symptoms 2
  • Sleep patterns and abnormalities 1, 2
  • Appetite and weight changes 2
  • Impulsivity and behavioral dyscontrol 1, 2
  • Obsessive-compulsive symptoms 3

Complete Psychiatric History

• Past and current psychiatric diagnoses 1, 2
• Prior psychotic ideation or experiences 1
• Prior aggressive behaviors (homicide attempts, domestic violence, threats, assault history) 1
• Complete suicidal history including:
  • Prior suicidal ideation with frequency and intensity 1
  • Prior suicide plans with specific methods considered 1
  • Prior suicide attempts with context, method used, medical damage sustained, lethality of attempt, and intent to die 1
• Psychiatric hospitalization history with dates, locations, and reasons 2
• Past psychiatric treatments (medications, psychotherapy, ECT, TMS) 2
• Response to previous treatments and adherence patterns 2

Comprehensive Substance Use History

• Tobacco use (type, quantity, duration) 3, 1, 2
• Alcohol use with pattern and quantity 1, 2
• Cannabis use 2
• Stimulant use (cocaine, methamphetamine, prescription stimulants) 2
• Opioid use (heroin, prescription opioids) 2
• Hallucinogen use 2
• Benzodiazepine use 2
• Misuse of prescribed medications 1, 2
• Misuse of over-the-counter medications and supplements 1, 2
• Current or recent substance use disorders with severity 1

Medical History

• Allergies and drug sensitivities with specific reactions 1
• Current medications: all prescribed medications, non-prescribed medications, supplements with dosages 1
• Primary care physician relationship and last visit 1
• Past and current medical illnesses 1
• Prior hospitalizations and surgeries 1
• Cardiopulmonary conditions 1, 2
• Endocrinological diseases (diabetes, thyroid disorders) 1, 2
• Infectious diseases: sexually transmitted diseases, HIV status, tuberculosis exposure, hepatitis C 1, 2
• Neurological conditions 2

Family History

• Psychiatric disorders in first-degree biological relatives (parents, siblings, children) 1
• Suicide attempts or completions in family members, particularly when patient has suicidal ideation 1
• Substance use disorders in family 2

Personal and Social History

• Trauma history including childhood abuse, domestic violence, sexual assault 1, 3
• Current psychosocial stressors:
  • Financial problems 1
  • Housing instability 1
  • Legal issues 1
  • Occupational problems 1
  • Relationship difficulties 1
• Educational history and highest level achieved 3
• Occupational history and current employment status 2
• Living situation and social supports 2
• Legal history including arrests and incarcerations 2

Physical Examination

• Vital signs: blood pressure, heart rate, respiratory rate, temperature 1, 2
• Height, weight, and body mass index calculation 1
• General physical examination findings relevant to psychiatric presentation 2

Mental Status Examination

Document nine core domains systematically: 4

• Appearance: grooming, hygiene, dress appropriateness, nutritional status 1, 2, 5
• Behavior: eye contact, psychomotor activity level, abnormal movements, cooperation with interview 1, 5
• Speech: rate, volume, fluency, articulation, spontaneity 1, 2, 5
• Mood: patient's subjective emotional state in their own words 1, 2, 5
• Affect: observed emotional expression including range, intensity, appropriateness, reactivity 1, 2, 5
• Thought Process: logical vs. illogical, linear vs. tangential, circumstantial, loose associations, flight of ideas 1, 2, 5
• Thought Content: suicidal ideation, homicidal ideation, delusions, obsessions, preoccupations 1, 2, 5
• Perceptual Disturbances: auditory hallucinations, visual hallucinations, other sensory distortions 2, 5
• Cognition: orientation to person/place/time/situation, attention and concentration, memory (immediate, recent, remote), executive function, abstract thinking 1, 2, 5
• Insight: awareness of illness and need for treatment 2, 5
• Judgment: decision-making capacity and understanding of consequences 2, 5

Comprehensive Risk Assessment

• Current suicidal risk assessment:

  • Current suicidal ideation (frequency, intensity, duration) 1, 2
  • Current suicide plans with specific methods 1, 2
  • Access to lethal means 2
  • Intent to act on suicidal thoughts 2
  • Possible motivations for suicide 2
  • Protective factors and reasons for living 2
  • Documented estimate of suicide risk level (low, moderate, high) with specific factors influencing the assessment 1

• Current violence risk assessment:

  • Current homicidal or aggressive ideation 1, 2
  • Current psychotic symptoms that could increase violence risk 1
  • History of violent behavior 1
  • Access to weapons 2
  • Documented estimate of violence risk with influencing factors 2

Diagnostic Impression and Treatment Plan

• Diagnostic formulation using DSM-5 criteria based on comprehensive assessment 3, 1
• Differential diagnoses considered 3
• Treatment plan with specific interventions:
  • Pharmacological treatments with rationale 3, 1
  • Non-pharmacological treatments with rationale 3, 1
• Patient's treatment preferences and goals 3, 1, 2
• Disposition plan and level of care determination 1

---

Follow-Up Visit Assessment Elements

For follow-up visits, conduct a focused update assessment that reviews changes since the last evaluation, current symptoms and mental status, treatment response, medication adherence and side effects, updated risk assessment, and revised treatment plan. 6, 2

Documentation Review

• Review existing comprehensive psychiatric assessment from intake 6
• Review previous treatment plans and interventions 6
• Review recent risk assessments 6

Interval History Since Last Visit

• Changes in psychiatric symptoms or mental status since last evaluation 6
• New stressors or life changes 6
• Adherence to prescribed treatments (medications and psychotherapy) 2
• Response to current treatment interventions 6, 2

Current Symptom Assessment

• Brief psychiatric review of systems focusing on target symptoms being treated 2
• Severity of symptoms using quantitative measures when appropriate 3

Medication Review

• Current medications with any recent changes 6
• Medication side effects or adverse reactions 3
• Effectiveness of current medication regimen 3

Focused Mental Status Examination

• Document changes from baseline in the nine core domains 4
• Particular attention to domains relevant to current treatment targets 2

Updated Risk Assessment

• Current suicidal ideation, plans, and intent 6, 2
• Current homicidal or aggressive ideation 6, 2
• Changes in risk level from previous assessment 6
• Updated protective factors 2

Revised Treatment Plan

• Modifications to pharmacological treatments with rationale 3, 2
• Modifications to non-pharmacological treatments with rationale 2
• Patient's ongoing treatment preferences 6, 2
• Plan for next follow-up 2

Documentation Requirements for Both Intake and Follow-Up

• Date and time of evaluation clearly documented 1, 2
• Authentication by evaluating clinician with signature 1, 2
• Rationale for treatment selection and modifications 2

---

Critical Pitfalls to Avoid

Never use "no-suicide contracts" as they are ineffective; instead, develop collaborative safety plans with specific coping strategies and crisis resources. 1

• Failing to review previous comprehensive documentation before follow-up visits wastes resources and burdens patients 6
• Overlooking substance use as a contributor to psychiatric symptoms leads to incomplete treatment 2
• Neglecting to assess trauma history misses important etiological factors 3, 1
• Performing routine laboratory testing without clinical indication in psychiatric patients with normal vital signs and non-contributory examinations is not evidence-based 2
• Diagnostic overshadowing (attributing all symptoms to known psychiatric diagnosis) prevents identification of new medical or psychiatric conditions 3