Structures comprehensive psychiatric evaluation with MSE, diagnostic formulation, and risk assessment. Use when performing psychiatric assessments, documenting mental status exams, or creating diagnostic formulations.
Structures comprehensive psychiatric evaluations with mental status examination, diagnostic formulation, and risk assessment in compliance with APA Practice Guidelines.
Why This Skill Exists
A comprehensive psychiatric evaluation is the foundation of all psychiatric treatment. Incomplete evaluations lead to missed diagnoses, inappropriate treatment, avoidable hospitalizations, and malpractice exposure. The APA Practice Guidelines for Psychiatric Evaluation of Adults (Third Edition) establish clear standards: evaluations must integrate chief complaint, history of present illness, psychiatric history, substance use history, medical history, family history, social/developmental history, mental status examination, risk assessment, and a multiaxial diagnostic formulation.
Regulatory and accreditation bodies including The Joint Commission (TJC), CMS Conditions of Participation, and state licensing boards mandate specific documentation elements for psychiatric evaluations. Failure to document a thorough evaluation has been the primary basis for malpractice claims in psychiatry, particularly when patients experience adverse outcomes that were foreseeable from information that should have been elicited during intake.
Checkpoint A: Pre-Draft Intake (Mandatory)
相關技能
What is the clinical setting? (inpatient, outpatient, emergency department, forensic, consultation-liaison) — default: outpatient
What is the referral question? (diagnostic clarification, medication management, risk assessment, fitness for duty) — default: diagnostic clarification
Is this an initial evaluation or follow-up reassessment? — default: initial
What is the patient's age group? (child/adolescent, adult, geriatric) — default: adult
Are there known safety concerns requiring immediate risk assessment? — default: unknown, assess at intake
What collateral sources are available? (family, prior records, referring provider notes) — default: none confirmed
What standardized instruments have been administered or are requested? (PHQ-9, GAD-7, PCL-5, AUDIT-C, Columbia Suicide Severity Rating Scale) — default: PHQ-9 and GAD-7
What is the expected output format? (narrative report, structured template, EHR-compatible note) — default: structured template
Documents to Request
Prior psychiatric evaluation reports and discharge summaries
Current medication list including dosages and prescribing dates
Primary care records including recent lab work (TSH, CBC, CMP, lipid panel, HbA1c)
School or occupational records if functional impairment is reported
Legal records if forensic questions are involved
Collateral statements from family members or caregivers
Previous treatment records including therapy notes and medication trials
Substance use treatment records including PDMP query results
Step 1: Identifying Information and Chief Complaint
Document demographics (age, sex, gender identity, pronouns, race/ethnicity, primary language, marital status, living situation, employment/education status). Record the chief complaint in the patient's own words using direct quotation marks. Note referral source and reason for referral. Document who is present during the evaluation and the patient's level of cooperation.
Identify the timeline of the presenting problem: onset, duration, severity trajectory, precipitating and exacerbating factors, alleviating factors, and prior treatment response. For each reported symptom, capture frequency, intensity, and functional impact.
Step 2: Psychiatric and Medical History
History of Present Illness (HPI)
Construct a chronological narrative of the current episode. For each symptom cluster, map to DSM-5-TR diagnostic criteria. Quantify severity using validated instruments where available (PHQ-9 score for depression, GAD-7 for anxiety, PCL-5 for PTSD, AUDIT for alcohol use).
Past Psychiatric History
Document in structured format:
Previous diagnoses with approximate dates
Previous hospitalizations (voluntary/involuntary, facility, length of stay, reason for admission)
Previous medication trials with dosages, duration, response, and reason for discontinuation
History of psychotherapy (modality, duration, response)
History of ECT or other neuromodulation therapies
History of suicide attempts (method, lethality, medical intervention required, precipitant)
History of self-harm behaviors
History of aggressive or violent behavior
Medical History
Document active medical conditions, surgical history, allergies, current medications (including OTC and supplements), and relevant family medical history. Flag conditions that mimic psychiatric illness: thyroid disorders, autoimmune conditions, seizure disorders, TBI, sleep apnea, substance-induced syndromes.
Substance Use History
Screen all patients using AUDIT-C for alcohol and DAST-10 for drugs. Document: substance, route, frequency, quantity, age of first use, pattern of use, periods of sobriety, withdrawal history, prior treatment episodes.
Step 3: Social and Developmental History
Document developmental milestones (if relevant), childhood environment, history of abuse or neglect, educational history (highest level achieved, learning difficulties, behavioral issues), occupational history, military service, relationship history, current living situation, support system, legal history, religious/spiritual beliefs, and cultural factors affecting presentation or treatment preferences.
Assess current functional status across domains: self-care, interpersonal relationships, occupational/academic performance, community engagement, and management of finances and legal affairs.
Step 4: Mental Status Examination (MSE)
Systematically document all MSE domains:
Appearance: Grooming, hygiene, attire, apparent age vs. stated age, distinguishing features, level of distress
Each DSM-5-TR diagnosis supported by documented criteria
Differential diagnosis explicitly addressed
Biopsychosocial formulation included
Treatment recommendations are specific and measurable
Collateral sources identified and noted whether obtained or unavailable
Cultural and linguistic factors addressed
Informed consent for evaluation documented
Evaluator credentials and date/time of evaluation recorded
Guidelines
Never document a diagnosis without supporting criteria — each DSM-5-TR diagnosis must reference the specific symptoms and duration thresholds met during the evaluation.
Always screen for suicidal ideation regardless of presenting complaint — document the screening even when negative.
Use direct quotes for chief complaint and key patient statements rather than paraphrasing subjective experiences.
Flag all [VERIFY] items for information that could not be independently confirmed during the evaluation.
Document medication allergies separately from intolerances (true allergy with immune response vs. side effect).
When cognitive concerns are present, administer and score a validated screening tool (MoCA preferred over MMSE for sensitivity to mild cognitive impairment).
Document the patient's decision-making capacity implicitly through the evaluation or explicitly if capacity is in question.
Include a clear safety plan disposition for any patient with identified suicidal ideation, regardless of assessed risk level.