Clinical Evaluation of the Psychiatric Patient 5
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 usually adirect quote from the patient.
C. History of present illness (HPI)1.
Current symptoms: date of onset, duration and course of symptoms.
Previous psychiatric symptoms and treatment.
Recent psychosocial stressors: stressful life events that may havecontributed to the patient's current presentation.
Reason the patient is presenting now.
This section provides evidence that supports or rules out relevantdiagnoses. Therefore, documenting the absence of pertinentsymptoms is also important.
Historical evidence in this section should be relevant to the currentpresentation.
D. Past psychiatric history1.
Previous and current psychiatric diagnoses.
History of psychiatric treatment, including outpatient and inpatienttreatment.
History of psychotropic medication use.
History of suicide attempts and potential lethality.
E. Past medical history1.
Current and/or previous medical problems.
Type of treatment, including prescription, over-the-counter medications, home remedies.
Relatives with history of psychiatric disorders, suicide or suicide attempts, alcohol or substance abuse.
G. Social history1.
Source of income.
Level of education, relationship history (including marriages, sexualorientation, number of children); individuals that currently live withpatient.
Current alcohol or illicit drug usage.
Family structure during childhood, relationshipswith parental figures and siblings; developmental milestones, peer relationships, school performance.
Mental Status Exam
. The mental status exam is an assessment of thepatient at the present time. Historical information should not be included inthis section.
A. General appearance and behavior 1.
Grooming, level of hygiene, characteristics of clothing.
Unusual physical characteristics or movements.
Ability to interact with the interviewer.
4. Psychomotor activity.
Agitation or retardation.