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Psychiatric History
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Anxiety
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Mood
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Psychosis
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Medical History
• • •
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Medical History
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Substance Use Status
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Substance Abuse
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Substance abuse intermittent
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Substance abuse continuous
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Social History
• • •
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Social History
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Present in the chart and review
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Contact family for more info
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Mental Status Exam
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Appearance
• • •
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Behavior
• • •
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Speech
• • •
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Mood
• • •
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Thought Process
• • •
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Affect
• • •
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Delusions
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Delusions
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Hallucinations
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Hallucinations
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Suicidal/Homicidal/Dangerousness
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Suicidal/Homicidal/Dangerousness
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Judgment/Insight
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Consciousness
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Orientation
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Intellectual Functioning
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Memory
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If long term impaired
/
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Assessment
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Level care medically necessary
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Psychiatric symptoms impairing
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Worsening depression
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Worsening anxiety
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Worsening of psychosis
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Without treatment anticipated
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Prevent deterioration
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DSM –IV Diagnosis
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Axis I
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Axis II
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Axis III
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Axis IV
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Axis V
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Initial Treatment Plan
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Group therapy
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1 on 1 counseling/psychotherapy:
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Medication and illness education
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Milieu treatment
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Medication monitoring
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Other
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