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PSYCHIATRIC EVALUATION
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Persons Present
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Source of Information & Decision-Maker
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Late cancellation/late arrival/no-show policy
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CC
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Psych History
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HPI
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Stressors
• • •
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SI/I/P
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HI/I/P
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NSSIB
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Women's Health
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Currently pregnant?
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Contraception
• • •
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Planning pregnancy within next year?
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Menopause
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Hysterectomy
• • •
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Men's health
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Nightly bathroom use
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REVIEW OF SYSTEMS
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Constitutional
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Integumentary
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Neuro
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HEENT
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CV
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Resp
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GI
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Endocrine
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GU
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Uro/GYN
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Hematologic/Lymphatic
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Allergic/Immunologic
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Musculoskeletal
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Acute/Chronic Pain
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MENTAL STATUS EXAM
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MSE
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Sensorium
• • •
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Appearance
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Attitude
• • •
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Behavior
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Speech
• • •
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Movement
• • •
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Mood
• • •
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Affect
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Depressive Symptoms
• • •
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Mania
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Anxiety
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Thought process
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Thought content
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Hallucinations
• • •
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Delusions
• • •
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Obsessive-Compulsive symptoms
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ADHD symptoms
• • •
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Impulse control
• • •
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PTSD symptoms
• • •
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Eating Disorder symptoms
• • •
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Appetite
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Sleep
• • •
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Concentration
• • •
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Cognition
• • •
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Judgment
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Insight
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MSE Comments
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Informed consent
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PSYCHOTHERAPY
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FORMULATION & PLAN
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ASSESSMENT
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Treatment Plan
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Patient Education
• • •
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Additional Education
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Follow-up appointment
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Agreement with Plan
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Follow-up questions
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