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Page 6 of 6 Initial Psychiatric Diagnostic Assessment Initials: Age: Sex: Marit

by | Aug 25, 2022 | Other | 0 comments

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Page
6
of 6
Initial Psychiatric Diagnostic Assessment
Initials:
Age:
Sex:
Marital Status:
Language:
Reason for Visit:
Information obtained from:
Allergies: (Include medication/food, adverse reaction and severity)
Chief Complaint: (patient concerns)
History of Presenting Illness: (Use the headings to delineate that each area is
addressed)
a. Context: (Describe the story of what is going on with the patient; Describe
chronic problem(s); Describe new problem(s); Describe what exacerbates the
problem; Describe what led to current status… off medications, stress,
progression of illness, substance abuse, past history trauma, etc.).
b. Location: (Describe the symptoms the patient is experiencing, such as, but not
limited to: mood swings; psychosis; paranoia; hallucinations; anxiety; depression;
panic attacks; PTSD; cognition problems, etc.).
c. Duration: {(Length of current/past episode(s); How long has this condition
lasted? Is it similar to a past problem? If so, what was done at that time?}.
d. Severity/Character: (mild, moderate, severe); (How bothersome is this
problem? Does it interfere with your daily activities? If so, explain in detail; Does
it keep you up at night?) {Try to have patient objectively rate the problem (Ask
patient to rate symptom from 1 to 10 with 10); If it affects their activity level,
determine to what degree this occurs.}
e. Timing: {Describe onset of symptoms- (i.e. 5 days ago; 1 month ago; 8 years
ago, but worsened over the past 3 weeks; etc.); Is the problem getting better,
worse, or staying the same? If it is changing, what has been the rate of change?}
f. Associated Symptoms: {Here you list all the symptoms in detail (describe
the story in more detail). (Describe the symptoms the patient is experiencing,
such as, but not limited to: mood swings (describe the mood swings- depressed,
then angry, then manic, etc.); Psychosis- specify type, such as paranoia
(describe the paranoia); Hallucinations (describe type of hallucination; are these
hallucinations command in nature? Non-command in nature? When do the
hallucinations occur? If auditory hallucinations, are they male or female? Are
they positive or negative voices? Provide an example by adding what the patient
says the voices say; and so on….}
g. Modifying Factors: (Here you can list social factors and/or medical factors that
may interfere or complicate treatment… homeless, death of spouse, lost job,
cancer, starting college, abuse, jail, DV, stress, divorce, etc.).
Psychosocial/Family History:
Relationship Status:
Children:
Support System:
Housing:
Income:
Education: (include if achieved developmental milestones on time child/adolescent)
Legal:
Abuse/Trauma:
Spirituality:
Military Service:
Cultural Concerns:
Past Psychiatric History:
Past Diagnosis: (list age of dx if known)
Past Suicide Attempts: (year or age, date if known, method, note if potentially lethal)
Past Violence:
Previous Admits: (when, where, why, brief list)
Outpatient Services:
Past Medication Trials:
Family Hx of Psychiatric Disorders:
Family Hx of Completed Suicide:
Substance Abuse History:
Nicotine: (explain type; quantity; route; etc)
ETOH: (explain type; quantity)
Caffeine: (explain form; amount; time of day used)
Illicit: (explain type; quantity; route; etc)
Prescriiption: (name drug; explain type; quantity; route; etc)
Substance Abuse Tx Hx: (explain type; quantity; route; etc)
Medical History:
Family Medical Hx:
Patient Medical/Surgical History:
Patient Current Medical Issues:
Current Scheduled Medications
(include name; dosage; route; frequency; reason for use, any side effects)
1.
2.
PRN Meds
1.
2.
Testing/Consult results: (Psychological testing, Speech evaluation, OT/PT)
PSYCHIATRIC ASSESSMENT
Sleep Schedule/Hygiene (include if snores):
Appetite:
Attending to Hygiene:
EPS:
MENTAL STATUS EXAM
(yes/no, WNL, Appropriate, Normal, intact are not appropriate for describing mental
status items. Describe the behavior or observed presentation)
Appearance:
Motor Activity:
Attitude:
Speech:
Affect:
Mood:
Thought Processes:
Thought content:
Suicidal ideation:
Homicidal ideation:
Self-Injury:
Cognition (estimate of intellect):
Orientation:
Memory:
Insight:
Judgement:
Psychomotor Activity:
Fund of Knowledge:
Cognitive Function Abilities:
Attention span-
Concentration-
Abstract thinking-
Concrete thinking-
Metaphors-
Standardized Assessment:
(ie. Beck Depression Inventory, Young Manie Rating Scale, PHQ-9)
Type:
Score:
Interpretation of Results:
Formulation:
Diagnoses (List in order of priority)-
Include DSM 5 code, identify data/symptoms of the assessment that support this
diagnosis, and if full or partial criteria is met
EXAMPLE:
Major Depressive Disorder single episode moderate, DSM 5 code F32.1. patient
describes feeling sad, nearly every day, most of the day, has stopped engaging in crafts
or reading she has enjoyed in the past, has decreased appetite and weight loss of 10 lb
in the past month, feeling tired throughout the day has no energy, but not sleeping at
night, is having trouble focusing at work, thoughts are drifting, does not feel as
productive at work. full criteria met.
1.
2.
Differential diagnosis (minimum of 2)
Include DSM 5 code, what data/symptoms need further follow up to rule in or rule out
these diagnoses, what additional questions would you ask, what additional
assessments would you want
EXAMPLE: Post Traumatic Stress Disorder, pt describes being a victim of rape, pt has
frequent memoires of these events which happen throughout during the day, at home
and at work, pt is upset when having to drive past the location where this occurred. Pt
will drive 5 miles out of the way on the way to work to avoid driving past the place where
the rape occurred. Pt feels disconnected from partner, can not describe a recent
experience of happiness, pt describes trouble concentrating at work, does not feel as
productive at work. These symptoms have been present for 6 weeks and are
contributing to poor work performance. Partial criteria met.
1.
2.
Plan: (minimum of 3 psychosocial interventions)
The focus is therapy, no lab work, medical tests or medication changes or suggestions
regarding medical issues are to be included, you are a therapist.
Current medications are to be listed, along with recommendation to follow up with the
individual prescribing medications, you may include a recommendation to see a medical
provider if indicated- rationale needed for each intervention)
Comprehensive plan, focus on addressing each diagnosis, must include at least one
topic of psychosocial education you would provide for your client with brief descriiption.
Must include at least one therapy, what kind and what type of therapy(theory), include
frequency. If needed address housing, financial, family and employment concerns.
Include brief rationale for all interventions.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Why this patient was chosen (a paragraph explaining why this client was selected, why
did you personally choose this client)
At least 2 questions regarding clinical decision-making psycho-social
issues/therapy/other treatment modalities, not related to agreement or disagreement
with the diagnosis, not related to medications, and not related other aspects of the
student response rubric the presenter would like other students to address.
Be thoughtful and challenge your peers to learn something new.

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