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Clinical Consult for Psychiatric Mental Health Care
This quick reference serves as an authoritative clinical guide to diagnostic ...
Current Clinical Strategies
Psychiatry2003-2004 Edition
Rhoda K Hahn, MD
Clinical Professor
DepartmentofPsychiatryand Human Behavior
University of California, Irvine, College of
Medicine
Lawrence J. Albers, MD
Assistant Clinical Professor DepartmentofPsychiatryand Human Behavior University of California, Irvine, College of Medicine
Christopher Reist, MD
Vice Chairman
DepartmentofPsychiatryand Human Behavior
University of California, Irvine, College of
Medicine
Current Clinical Strategies Publishing www.ccspublishing.com/ccs
Digital Book and Updates
Purchasers of this book can download thedigital book and updates via the Internetat www.ccspublishing.com/ccs.Copyright ©2003-2004 Current ClinicalStrategies Publishing. All rights reserved.This book, or any parts thereof, may notbe reproduced, photocopied or stored inan information retrieval network withoutthe permission of the publisher. No warrantyfor errors or omissions exists, expressedor implied. Readers are advised to consultthe drug package insert and other referencesbefore using any therapeutic agent. CurrentClinical Strategies is a registered trademarkof Current Clinical Strategies Publishing.Current Clinical Strategies Publishing27071 Cabot RoadLaguna Hills, California 92653-7011Phone: 800-331-8227Internet: www.ccspublishing.com/ccsE-mail: info@ccspublishing.comPrinted in USA ISBN 1-929622-30-9
Assessment and Evaluation
Clinical Evaluation of the Psychiatric Patient
I. Psychiatric HistoryA. Identifying information.
Age, sex,marital status, race, referral source.
B. Chief complaint (CC).
Reason for consultation; the reason is usuallya direct quote from the patient.
C. History of present illness (HPI)1.
Current symptoms: date of onset,duration and course of symptoms.
2.
Previous psychiatric symptomsand treatment.
3.
Recent psychosocial stressors:stressful life events that may havecontributed to the patient's currentpresentation.
4.
Reason the patient is presentingnow.
5.
This section provides evidencethat supports or rules out relevantdiagnoses. Therefore, documentingthe absence of pertinentsymptomsis also important.
6.
Historical evidence in this sectionshould be relevant to the currentpresentation.
D. Past psychiatric history1.
Previous and current psychiatricdiagnoses.
2.
History of psychiatric treatment,including outpatient and inpatienttreatment.
3.
History of psychotropic medicationuse.
4.
History of suicide attempts andpotential lethality.
E. Past medical history1.
Current and/or previous medicalproblems.
2.
Type oftreatment,includingprescription,over-the-counter medications,home remedies.
F.
Family history.
Relatives with historyof psychiatric disorders, suicide or suicide attempts, alcohol or substanceabuse.
G. Social history1.
Source of income.
2.
Level of education, relationshiphistory(including marriages, sexualorientation, number of children);individuals that currently live withpatient.
3.
Support network.
4.
Current alcohol or illicit drug usage.
5.
Occupational history.
H. Developmental history.
Familystructureduring childhood, relationships withparental figures and siblings; developmentalmilestones, peer relationships, schoolperformance.
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Psychiatry
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