45-Minute New Patient Psychiatric Evaluation Script for Nurse Practitioners
Structure your initial psychiatric evaluation using the APA-recommended framework, systematically covering all critical domains within the 45-minute timeframe while prioritizing safety assessment and collaborative treatment planning 1.
Time Allocation Framework (45 minutes total)
- Minutes 0-5: Introduction, rapport building, chief complaint
- Minutes 5-15: History of present illness and psychiatric review of systems
- Minutes 15-25: Psychiatric, substance use, and medical histories
- Minutes 25-30: Family and psychosocial history
- Minutes 30-35: Mental status examination
- Minutes 35-40: Risk assessment (suicide/violence)
- Minutes 40-45: Collaborative treatment planning and patient education
Opening (0-5 minutes)
Introduce yourself and establish rapport:
- "I'm [Name], a psychiatric nurse practitioner. Today we'll spend about 45 minutes together so I can understand what brings you here and how we can help."
- Assess if interpreter needed 1
- Obtain consent for evaluation
- Ask: "What brings you in today?" and "What are you hoping to get from our visit?"
History of Present Illness (5-15 minutes)
Systematically assess current symptoms:
Chief Complaint & Timeline
- When did symptoms start? What was happening in your life then?
- How have symptoms progressed or changed?
- What makes symptoms better or worse?
Psychiatric Review of Systems 1
Ask specifically about:
- Mood: Depression, sadness, emptiness, irritability
- Anxiety: Worry, panic attacks (frequency, triggers, physical symptoms)
- Sleep: Difficulty falling asleep, staying asleep, early morning awakening, sleep apnea symptoms, hypersomnia
- Energy/Motivation: Fatigue, anhedonia, ability to complete daily tasks
- Concentration/Memory: Difficulty focusing, forgetfulness
- Appetite/Weight: Changes in either direction, amount and timeframe
- Psychotic symptoms: Hallucinations (auditory, visual), delusions, paranoia
- Impulsivity: Reckless behaviors, spending, sexual activity, substance use 1
Psychiatric History (15-20 minutes)
Past Diagnoses & Treatment 1
- "Have you ever been diagnosed with a mental health condition?"
- Previous psychiatric hospitalizations (when, where, how long, voluntary vs. involuntary)
- Emergency department visits for psychiatric reasons
- Past medications tried (names, doses, duration, response, side effects)
- Past therapy (type, duration, helpfulness)
- Critical question: "What treatments have worked best for you in the past?"
Suicide & Self-Harm History 1
- Prior suicidal thoughts, plans, or attempts (get specific details):
- Context of each attempt
- Method used
- Medical damage/lethality
- Intent to die vs. other motivations
- Aborted or interrupted attempts
- Non-suicidal self-injury (cutting, burning, etc.)
Violence/Aggression History 1
- Prior thoughts of harming others (homicide, physical/sexual aggression)
- History of violent behaviors (domestic violence, workplace violence, assault)
- Legal consequences of aggressive behaviors
- Weapons access (especially firearms)
Substance Use History (20-22 minutes)
Ask about all substances systematically 1:
- Tobacco (type, amount, years)
- Alcohol (drinks per week, binge drinking, blackouts)
- Cannabis (frequency, method, THC concentration)
- Stimulants (cocaine, methamphetamine, prescription misuse)
- Opioids (prescribed or illicit)
- Benzodiazepines
- Hallucinogens
- Over-the-counter medications or supplements
For each substance used:
- Age of first use
- Current frequency and amount
- Last use
- Withdrawal symptoms
- Impact on functioning
- Prior treatment attempts
Medical History (22-24 minutes)
Current Medical Status 1
- Allergies (medication allergies and reactions)
- Current medications (all prescriptions, OTC, herbals, supplements, vitamins—get exact names and doses)
- Primary care provider (name, last visit)
- Chronic medical conditions (diabetes, hypertension, thyroid disease, heart disease)
- Neurological conditions (seizures, head injuries, stroke, dementia symptoms)
- Endocrine disorders
- Infectious diseases (HIV, hepatitis C, sexually transmitted infections)
- Chronic pain conditions
- Sexual/reproductive history (pregnancy, menstrual issues, sexual dysfunction)
Physical Examination Elements 1
If feasible in your setting, obtain:
- Height, weight, BMI
- Vital signs (BP, pulse, temperature)
- General appearance and nutritional status
- Observe for stigmata of self-injury or substance use
Family History (24-26 minutes)
Ask about biological relatives 1:
- Psychiatric diagnoses (depression, bipolar disorder, schizophrenia, anxiety disorders)
- Substance use disorders
- Suicide attempts or completions
- Violence or aggressive behaviors
- Medical conditions (especially neurological, endocrine)
Personal & Social History (26-28 minutes)
Current Psychosocial Stressors 1
- Financial problems
- Housing instability
- Legal issues
- Occupational/school problems
- Relationship conflicts
- Lack of social support
- Recent losses or trauma
Trauma History 1
- Childhood abuse (physical, sexual, emotional, neglect)
- Domestic violence
- Combat exposure
- Assault or violent victimization
- Witnessing violence
Cultural Factors 1
- Cultural background and identity
- Religious/spiritual beliefs
- Cultural explanations of illness
- Immigration history if applicable
- Language preferences
Developmental/Educational History
- Highest education level
- Learning disabilities
- Childhood behavioral problems
Mental Status Examination (28-33 minutes)
Observe and document systematically 1:
Appearance & Behavior
- Grooming, hygiene, dress
- Eye contact
- Psychomotor activity (agitation, retardation)
- Abnormal movements
Speech
- Rate, volume, tone
- Fluency and articulation
- Spontaneity
Mood & Affect
- Stated mood ("How would you describe your mood?")
- Observed affect (range, appropriateness, intensity)
- Level of anxiety
Thought Process & Content
- Organization (linear, tangential, circumstantial, loose associations)
- Suicidal ideation (passive vs. active)
- Homicidal ideation
- Delusions
- Obsessions
Perception
- Hallucinations (auditory, visual, tactile)
- Illusions
- Depersonalization/derealization
Cognition
- Orientation (person, place, time, situation)
- Attention and concentration
- Memory (immediate, recent, remote)
- Insight and judgment
Safety Risk Assessment (33-38 minutes)
Current Suicide Risk 1
If any suicidal ideation present, assess:
- Frequency and intensity of thoughts
- Specific plan (method, location, timing)
- Intent to act on thoughts
- Access to means (firearms, medications, other lethal means)
- Rehearsal behaviors (writing notes, giving away possessions)
- Protective factors:
- Reasons for living (children, family, pets, religious beliefs)
- Future orientation
- Willingness to engage in safety planning
- Hopelessness level (strong predictor of suicide risk) 1
- Motivations (escape pain, revenge, command hallucinations, delusional guilt)
- What would you do if symptoms worsen tonight?
Current Violence Risk 1
If aggressive ideation present, assess:
- Specific target identified
- Plan and means
- Intent to act
- History of violence toward this person
- Access to weapons
- Substance use
- Command hallucinations
- Paranoid delusions about target
Document risk level and contributing factors 1
Collaborative Treatment Planning (38-45 minutes)
Explain Findings 1
- "Based on what you've told me, here's what I'm thinking..."
- Discuss differential diagnosis in understandable terms
- Explain how symptoms fit diagnostic criteria
- Discuss risks of untreated illness 1
Treatment Options 1
Present evidence-based options with benefits and risks:
Medication options:
- Specific medications recommended
- Expected benefits and timeline
- Common side effects
- Serious but rare risks
- Monitoring requirements
Psychotherapy options:
- Types appropriate for diagnosis (CBT, DBT, IPT, etc.)
- Expected frequency and duration
- How therapy works for this condition
Other interventions:
- Lifestyle modifications (sleep hygiene, exercise, substance cessation)
- Support groups
- Case management if needed
Shared Decision-Making 1
- "What are your preferences for treatment?" 1
- Discuss patient's concerns about specific treatments
- Incorporate cultural and personal values
- Address barriers to treatment (cost, transportation, stigma)
- Negotiate realistic treatment plan
Safety Planning
If suicide risk present:
- Identify warning signs
- Internal coping strategies
- Social contacts for distraction
- Family/friends who can help
- Professional contacts and crisis numbers
- Means restriction (especially firearms)
- Written safety plan provided
Follow-Up
- Schedule next appointment (typically 1-4 weeks depending on acuity)
- Provide crisis contact information
- Clarify when to seek emergency care
- Coordinate with primary care if needed
Critical Documentation Elements 1
Your note must include:
- Suicide risk estimate with supporting factors
- Violence risk estimate if applicable (with supporting factors)
- Rationale for treatment selection
- Patient's treatment preferences
- Differential diagnosis
- Treatment plan with specific interventions
- Follow-up plan
Common Pitfalls to Avoid
Rushing safety assessment: Never abbreviate suicide/violence risk evaluation—this is non-negotiable for patient safety and medicolegal protection 1
Failing to assess past treatment response: This is your best predictor of future response 1
Ignoring substance use: Substance use dramatically affects psychiatric diagnosis and treatment 1
Missing medical contributors: Thyroid disease, sleep apnea, neurological conditions can mimic or exacerbate psychiatric symptoms 1
Not documenting risk assessment: Even if risk is low, document your assessment and reasoning 1
Skipping collaborative decision-making: Patients who participate in treatment decisions have better adherence and outcomes 1
Overlooking cultural factors: Cultural beliefs about mental illness affect help-seeking, symptom expression, and treatment acceptance 1
The APA guidelines emphasize that clinical judgment is essential for tailoring this evaluation to individual patient circumstances 1. Some elements may need to be deferred to subsequent visits based on patient acuity, cooperation, and time constraints 1.