What should be included in a comprehensive, structured psychiatric initial evaluation?

Comprehensive Psychiatric Initial Evaluation

Essential Documentation Framework

A comprehensive psychiatric initial evaluation must include: identifying information with date/time and information sources; chief complaint in the patient's own words; chronological history of present illness with psychiatric review of systems; complete psychiatric history including prior diagnoses, suicide attempts (method, lethality, intent, context), and aggressive behaviors; substance use assessment covering tobacco, alcohol, illicit drugs, and medication misuse; medical history with current medications, allergies, and cardiopulmonary/endocrine/infectious disease screening; family psychiatric history; psychosocial stressors and trauma history; physical examination with vital signs and BMI; mental status examination; quantitative symptom measures; and risk assessment with documented suicide and violence risk estimates. 1, 2

Core Assessment Domains

Identifying Information and Context

• Document patient demographics (name, age, gender, date of birth), date/time of evaluation, and all information sources (patient, family, prior records) 2
• Record the chief complaint using the patient's exact words and document circumstances leading to the evaluation 2

History of Present Illness

• Establish a detailed chronology of symptom development, including onset, duration, progression, and triggers 2
• Conduct a systematic psychiatric review covering:
  • Depressive symptoms (mood, anhedonia, neurovegetative signs) 2
  • Anxiety symptoms and panic attacks 2
  • Psychotic symptoms (hallucinations, delusions, disorganization) 1
  • Sleep patterns and abnormalities, including screening for sleep-disordered breathing 2
  • Impulsivity and behavioral dyscontrol 2
• Quantify the proportion of time the patient is preoccupied with symptoms and evaluate resulting psychosocial impairment 2

Psychiatric History

• Document all past and current psychiatric diagnoses, recognizing that misdiagnosis at illness onset is common and periodic reassessment is necessary 2
• Obtain complete details of prior suicidal ideation, plans, and attempts, including context, method, medical damage, lethality, and intent 2
• Assess history of aggressive behaviors, including homicide, domestic violence, threats, and prior psychotic or aggressive ideation 2
• Record all previous psychiatric treatments:
  • Medications (drug name, dosage, duration, therapeutic response, side effects, reasons for discontinuation) 2
  • Psychotherapy (type, duration, perceived benefit) 2
  • Psychiatric hospitalizations (dates, reasons, length of stay, treatments received) 2
  • Somatic treatments such as electroconvulsive therapy 2

Substance Use Assessment

• Evaluate use of tobacco, alcohol, and illicit substances 1, 2
• Assess misuse of prescribed medications, over-the-counter drugs, and supplements 2
• Identify current or recent substance use disorders 2

Medical History and Physical Health

• Document allergies and drug sensitivities 2
• List all current medications (prescribed, non-prescribed, supplements) 2
• Assess primary care relationship and access to preventive health care 2
• Review past and current medical illnesses and hospitalizations 2
• Evaluate cardiopulmonary status, endocrinological disease, and infectious diseases (sexually transmitted infections, HIV, tuberculosis, hepatitis C) 2
• Perform focused neurological screening for seizures, head injuries, or loss of consciousness 2
• Recognize that lithium, valproic acid, and clozapine can produce psychiatric side effects 2

Developmental and Educational History

• Inquire about prenatal and birth complications and early developmental milestones (walking, talking, toilet training) 2
• Explore early childhood behavior and temperament 2
• Document academic history, including performance, grade retention, and special education services 2

Family History

• Assess psychiatric disorders in biological relatives 2
• For patients with suicidal ideation, specifically evaluate family history of suicidal behaviors 2

Psychosocial and Cultural Factors

• Identify current psychosocial stressors (financial, housing, legal, occupational, relationship problems) 1, 2
• Assess trauma history 1, 2
• Avoid stereotyping or profiling based on race or culture when assessing dangerousness 1
• Consider cultural and peer influences in the patient's environment 1

Physical Examination

• Measure and record height, weight, and body mass index 2
• Document vital signs: temperature, resting heart rate, blood pressure, and orthostatic pulse and blood pressure 2
• Inspect physical appearance for evidence of malnutrition or purging behaviors 2

Mental Status Examination

• Assess appearance and behavior 2
• Evaluate speech fluency and articulation 2
• Document mood (patient's subjective state) and affect (observed emotional expression) 2
• Examine thought process (logical, tangential, circumstantial, flight of ideas, loose associations) 2
• Assess thought content, including delusions, obsessions, suicidal or homicidal ideation 1
• Perform cognitive assessment 1

Quantitative Symptom Assessment

Use a quantitative measure to identify and determine the severity of symptoms and functional impairments that may be a focus of treatment. 1 This provides objective tracking of treatment response and enhances diagnostic accuracy.

Laboratory and Diagnostic Testing

• Obtain complete blood count and comprehensive metabolic panel (electrolytes, liver enzymes, renal function) in every patient to detect metabolic abnormalities 2
• Conduct electrocardiogram in patients with restrictive eating disorders, severe purging behaviors, or those receiving QT-prolonging medications 2

Risk Assessment

Suicide Risk

• Evaluate current suicidal ideation, plans, intent, and access to means 1, 2
• Document a comprehensive estimate of suicide risk, including protective and risk factors 2
• Use safety planning rather than no-suicide contracts 2

Violence Risk

• Assess current aggressive or homicidal ideation 1, 2
• For patients with history of aggression, evaluate specific triggers and responses to prior interventions 1, 2
• Consider physical characteristics (size, strength) and their implications for safety planning in inpatient settings 1
• Use standardized aggression scales (e.g., Overt Aggression Scale, Brief Psychiatric Rating Scale) to track aggressive behavior and alert staff to potential dangers 1

Treatment Planning

Develop a documented, comprehensive, person-centered treatment plan that includes evidence-based nonpharmacological and pharmacological treatments. 1 The plan must:

• Specify targeted symptoms and functional impairments 2
• Incorporate the patient's treatment goals and preferences 1, 2
• Be culturally appropriate and delivered by a coordinated multidisciplinary team when indicated 2
• Include evidence-based psychotherapies (cognitive-behavioral therapy, dialectical behavior therapy, interpersonal therapy, or family therapy) with specified frequency and duration 2
• For pharmacotherapy, obtain informed consent covering:
  • Specific symptoms targeted 2
  • Expected benefits and timeline for response 2
  • Common and serious adverse effects 2
  • Risks of non-treatment 2
  • Alternative therapeutic options 2
  • Monitoring plan with follow-up frequency 2
  • Instructions for managing problems or side effects 2

Critical Pitfalls to Avoid

• Do not attribute behavioral or emotional reactions stemming from psychosocial stressors to underlying biological illness, as this leads to unnecessary medical interventions and overlooks needed psychosocial support 3
• Recognize that intake staff must be trained in child development, psychopathology, and risk factors for aggression, and must communicate findings clearly to the admitting psychiatrist 1
• Ensure staff can meet the needs of linguistic and cultural minorities 1
• When diagnostic uncertainty exists, educate patients about the provisional nature of the diagnosis and the possibility of future revisions 2

Documentation Standards

• All sections must be clearly documented with date and time 2
• Authentication by the evaluating clinician is required 2
• Consent is not a one-time event; revisit and reaffirm consent whenever treatment plans change 2