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The ideal psychiatric
interview/write-up/presentation is one in which the presenter
is able to convey clinically relevant information in a clear,
concise, organized manner. A good presenter will leave a "picture"
of the patient being presented in the other's mind after the presentation
is completed, making it easier to formulate a problem list and
differential diagnosis.
The following format is generally accepted, with mild alterations
made per individual attending.
I. Identifying Information
Start the write-up/presentation with a clear statement about
the patient which helps the listener/reader get a picture of the
person. Example : 54 yo married white female who is 8 months pregnant.
II. Chief Complaint
This is the patient's chief complaint, and you should write down
what the patient states is the reason for coming in to be evaluated.
Do not use technical terminology unless the patient does - rather,
put down exactly what the patient says usually in quotations.
Example : Patient's chief complaint is : "I feel depressed;"
patient's chief complaint is : "I need a refill of medicine."
III. History of Present Illness
Write down an organized, chronological history of what brings
the patient into the hospital now, including all significant symptomatology,
precipitating factors, etc... If the patient is presenting to
you with a six month history of depression which started when
the patient's father died, start six months ago with the death
of the father and report what has been going on since then, in
chronological order, up until the current time of the interview.
Include significant modifiers of the illness, including possible
organic factors, drug, and alcohol abuse. List all pertinent
positive and negative symptoms, which will help you to make an
accurate DSM-IV (differential) diagnosis.
IV. Past Psychiatric History
Put in all contact the patient has had with therapists (psychiatrists,
psychologists, social workers, and counselors), inpatient units,
and other outpatient experiences. Be sure to include prior rehabilitation
programs. If the patient has been on psychotropic medications
in the past, list these by date, how long the patient took each
one, at what dose, and the effect the medication had on the patient.
List any ECT the patient might have had. Also list prior suicide
attempts and methods.
V. Past Medical History
List in this area any current medical problems the patient has,
and then any past medical, surgical or obstetric problems the
patient has had, in chronological order. List the hospitalizations.
List all medications (including doses) the patient is currently
taking. List any allergies the patient has and what the specific
reactions to the medications were.
VI. Family History
A genogram is often useful here for clarity. List all illnesses
that patient's family has had, including medical, psychiatric,
and substance abuse history. Write down any psychotropic medications
which have been beneficial in family members. Include suicide
attempts or completed suicide in family members. Include
whether the family members are currently living or are dead. Include
patient's parents, siblings, and children.
VII. Social History/Developmental History
List all substances the patient currently is taking; drugs, alcohol,
cigarettes. List how much the patient uses of each, how often,
for how many years and in what form (smoke, IV, etc...). Document
when the last time used. List patient's educational history,
work history, and what the patient currently does to support himself/herself.
Are there any ongoing legal issues, felonies, warrants, etc...
Ask who the patient currently lives with. Ask about the patient's
marital status, sexual orientation, sexual activity, children,
etc...
VIII. Review of systems
Put in this category any other information you might have received;
i.e., the patient told you he is short of breath a lot,
he has blurred vision. It is sometimes useful to ask a patient
to tell you anything he considers important for you as the physician
to know that you have not yet asked.
IX. Mental Status Exam
The mental status exam is extremely important. The best mental
status exams allow the person listening to the presentation to
develop a snapshot of the patient being presented.
Appearance : Start out the mental status exam by giving
a verbal picture of the patient, what the patient is doing, wearing,
and how the patient looks. For example : 16 yo BM wearing age
appropriate dress of clean jeans, a t-shirt, and sneakers with
the laces undone. He was sitting on the floor playing with a train
set. He looked up and smiled when the interviewer approached.
16 yo BM O X 3 is a lot less descriptive!
After the initial description you have probably already taken
care of the general appearance, alertness, hygiene and grooming
part of the general description, but if not, include some information
here. Look for use of grooming that might be suggestive of a mood
state or disorganization. Don't use diagnostic labels, just describe
what you see.
Speech : volume, rate, idiosyncratic symbols or other
odd speech, tone (include any accent or stuttering).
Motor activity : rate (agitated, retarded), purposefulness,
adventitious (non-voluntary).
Mood : ask how they are feeling, usually put in quotes
: "depressed," "sad," "great," etc...
Affect : observable emotion (euthymic, neutral, euphoric,
dysphoric, flat), the range (full, constricted, blunted), whether
it fits appropriate to stated mood or content, lability.
Thought process : organization of a person's thoughts
(logical/linear, circumstantial, tangential, flight of ideas,
loose associations or thought blocking).
Thought content : basic themes preoccupying the patient,
sucidality, homicidality, paranoia, delusions, ideas of reference,
obsessions, compulsions. If there is suicidal or homicidal
ideation, is there a plan, intent?
Perceptual disturbances : hallucinations (auditory, visual,
olfactory, tactile), illusions, de-realization/depersonalization.
Cognitive : level of alertness and orientation.
May want to perform full Folstein MMSE if concerned about dementia
or delirium.
Insight : into level of illness and/or need for treatment/hospitalization.
Judgment/Impulse control : best determined by history
of patterns of behavior and current attitude.
IX. Physical Exam
Many medical diseases masquerade as psychiatric, and vice versa
(pancreatic CA, hypothyroidism, brain metastases). Do a thorough
PE including full neurological exam and document. This usually
does not include a breast, pelvic, rectal, or genital exam
on inpatients.
X. Problem List
XI. Differential Diagnosis
XII. Plan Include biological (medications, labs, studies),
psychological (individual therapy, group therapy, psychological
testing), and social (housing, access to care, social services),
interventions.
MULTI AXIAL ASSESSMENT
Axis I |
Clinical Disorders
Other conditions that may be a focus of clinical attention |
Axis II |
Personality Disorders/Traits
Mental Retardation |
Axis III |
General Medical Conditions influencing diagnosis, treatment,
or prognosis of Axis I or II disorders |
Axis IV |
Psychosocial and Environmental Problems
i.e., problems with primary support group, problems related
to the social environment, educational problems, occupational
problems, housing problems, economic problems, problems
with access to health care services, problems related to
interaction with the legal system/crime, other. |
Axis V |
Global Assessment of Functioning
This scale is for reporting the clinicians judgment of
the individual's overall level of functioning. This information
is useful in planning treatment and measuring its impact
and in predicting outcome. The scale ranges from "0"
- (inadequate information), to "100" (no symptoms
and superior functioning in a wide range of activities). |
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