Complete Psychiatric Assessment and Evaluation
Sat, 03/15/2008 - 14:44 — saif
Psychiatric Assessment and Evaluation
Location:
Patient Information: Name: Age:
Gender:
Marital Status: Race: Referral Source:
Chief Complaint
HPI
Date of Onset:
Duration:
Course of Symptoms:
Psychological Stressors:
*get feel for patient’s issue and adapt ROS (checklist for that specific issue).
Past Psychiatric History:
Diagnosis:
Trauma:
Chemical Dependencies:
Violence (self/others):
Treatment:
Med/Surgical History:
Psychosocial History:
Childhood:
Relationship to Children:
Living Situation:
Employment/income:
Legal issues:
Education:
Substance abuse (illicit drugs, tobacco, alcohol)
Medications:
Allergies:
ROS (checklist)
Mental Status Exam:
I. General Description
a. Appearance (well groomed, )
b. Behavior and psychomotor activity (appropriate,)
c. Attitude (cooperative, aggressive, )
II. Mood and affectivity
II. Mood and affectivity
a. Mood (neutral, euphoric, depressed, anxious, irritable)
b. Affect (full, flat, blunted, inappropriate)
c. Appropriateness
III. Speech
IV. Perception
V. Thought
a. Content – hallucinations, delusions, illusions, derealization, depersonalization, suicidal/homicidal ideation.
b. Process (handout) -- pressured speech, poverty of speech, circumstantiality, tangentiality,
VI. Sensorium and Cognition
a. Consciousness
b. Orientation and memory
c. Concentration and attention
d. Reading and writing
e. Visuospatial ability
f. Abstract thought
g. Info and intelligence
VII. Impulsivity
VIII. Judgment, Insight, Reliability
Multiaxial Assessment Diagnosis
Axis I – clinical disorders
Axis II – personality/mental disorders
Axis III – general medical conditions
Axis IV – Psychosocial + environmental problems
Axis V – Global Assessment of Function
Treatment Plan:
General Medical Screening (labs):