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SAMPLE-Psych Assessment Elements & Histroy Taking Questions

The document outlines the key components of a psychiatric assessment, including the chief complaint, present illness, psychiatric review of systems, treatment history, substance abuse history, family history, developmental and social history, sexual history, medical/surgical history, mental status examination, diagnostic impression, and treatment plan. Each section provides specific examples and questions to guide the assessment process. The goal is to gather comprehensive information to inform diagnosis and treatment planning for psychiatric patients.

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Jennifer Teeters
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93 views5 pages

SAMPLE-Psych Assessment Elements & Histroy Taking Questions

The document outlines the key components of a psychiatric assessment, including the chief complaint, present illness, psychiatric review of systems, treatment history, substance abuse history, family history, developmental and social history, sexual history, medical/surgical history, mental status examination, diagnostic impression, and treatment plan. Each section provides specific examples and questions to guide the assessment process. The goal is to gather comprehensive information to inform diagnosis and treatment planning for psychiatric patients.

Uploaded by

Jennifer Teeters
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Elements of the Psychiatric Assessment

Chief Complaint
Reason patient gives for presenting for treatment at this time; usually a direct quotation.

Example:

"I'm depressed."

Present Illness
Recent psychiatric symptoms (pertinent positives and negatives).
 Timeframe of recent onset or exacerbation.
 Triggers (stressful life events).
 Recent treatment and treatment changes (new meds, dosage increases or
decreases, med compliance, therapy frequency, etc.)

Example:

If depressed, report all SIGECAPS.


 If manic, report all DIGFAST, etc.
 Always report presence or absence of suicidality.
 One key trick is to stick to a description of "this episode." Begin by working to define
the current episode (often, why they came to the hospital). Often not easy with
chronic patients or patients with poor insight into their illness. You can assume that if
they are now hospitalized, something has changed.

Psychiatric Review of Systems


Screen for present and past:
 Major depressive/dysthymic symptoms.
 Manic or hypomanic symptoms.
 Psychotic symptoms.
 Generalized anxiety disorder.
 Panic disorder.
 Obsessive-compulsive disorder.
 Other areas suggested by HPI, for example:
o Dementias
o Eating disorders
o Dissociative disorders
o PTSD
Example:

 MDD: SIGECAPS
 Mania: DIGFAST
 Psychotic symptoms, always screen for:
o Hallucinations: do you hear things that others don't hear?
o Paranoia: do you feel safe here? How about at home? Is anyone bothering you
or trying to harm you?
 If indicated, also screen for:
o Grandiosity: do you have any special powers or abilities?
o Referential thinking: do you ever feel like the TV or radio or newspapers are
referring directly to you?
o Thought broadcasting: do you ever feel that others can hear your thoughts or
that others are stealing your thoughts?
 GAD: do you worry excessively? Often feel your worry is out of control? Muscle
tension? Irritability? Fatigue? Poor concentration? Restless?
 Panic: attacks out of the blue? How long do they last?
 OCD: anything you feel that you must do over and over again? What happens if you
don't do it? How much time do you spend? Does it interfere?

Psychiatric Treatment History


 Inpatient: past psychiatric hospitalizations.
o Number in life
o Most recent: when, where, why, what meds?
o Remote: year, where, why?
 Outpatient: past outpatient treatment.
o Most recent: where, who, how often seen?
o Remote: years, where, who?
 Medications: what has been tried in the past?
o What, when, dose, how long, response, side affects?
 Suicide history
o Ever seriously considered in life? When? What was going on?
o Ever tried to kill yourself? When? How?
o How many times in life?
o When most recently? How?
o Have you been feeling suicidal lately? Now? Plan? Safe in hospital?
 Violence history
o What is the most violent thing you've ever done in your life?
o Are you feeling at all violent now?
o What if you happened to meet (potential victim) in a dark alley?
 Psychotherapy: what type? How long? Response?

Substance Abuse History


 Each drug (including alcohol).
o First use
o Heaviest use, when?
o Consequences of use (legal, relationship, health, etc.)
o Recent pattern of use, last use
 Rehab, AA, NA

Family History
 Any psychiatric illness in family?
 Any substances abuse in family?
 Any suicide in family?

Developmental and Social History


 Where born?
 Normal pregnancy and birth?
 Describe childhood in a word or two.
 Abuse of any type?
 Parents — marital status, who raised patient, occupations.
 Relationships, marriages, divorces, children.
 Education: how much? Why left? Type of student? Trouble (suspensions)?
 Occupation/economic
o Military, job history
o Disability (SSI/SSD)
 Legal — arrests, for what, prison time
 Spiritual

Example:

Be flexible. If patient needs to be drawn out more and if time allows, begin this section with
an open-ended question like, "Tell me what it was like for you growing up." If patient is
hyperverbal and/or tangential, begin with closed-ended questions.

Sexual History
 Sexually active currently?
 When last?
 Any problems?
 Contraception?
 Any chance of pregnancy?

Medical/Surgical History
 Significant medical illnesses, medical hospitalizations, surgeries, seizures, head
injuries with loss of consciousness

Mental Status Examination


Observational components:
 Attitude (cooperative, easily engaged in conversation)
 Appearance (normal)
 Hygiene and grooming (good)
 Affect (range of emotional expression)
 Speech (rate, volume, articulation)
 Thought process (logical and linear)
 Insight (do they understand that they have a mental illness and need treatment?)
If unsure, ask.
Direct Inquiry components:
 Mood (patient's description and rating 1–10; 10 = best)
 Hallucinations
 Delusions
 Suicidal and violent ideation
 Cognitive exam:
o Orientation
o Register and recall (three words)
o Attention and concentration (WORLD backwards)
o Abstraction (proverb)
o Current events
o Judgment (stamped envelope)

Example:

Ask these items of every patient during an initial assessment. Do the full Mini-Mental State
Examination if delirium, dementia, or other cognitive change is in the differential diagnosis.

Diagnostic Impression
 Summary of clinical findings and diagnostic impressions
 Differential diagnosis if applicable
 Final DSM-5 diagnosis (include all relevant codes and specifiers)

Treatment Plan
 Psychopharmacological interventions (medication changes, dosages, and
rationale)
 Psychotherapeutic approaches (type, frequency, and goals)
 Recommendations for lifestyle changes or behavioral strategies
 Referrals (e.g., therapy, substance use programs, social services)
 Safety planning (e.g., crisis hotline information, follow-up scheduling)

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