Conducting Psychiatric Evaluations
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)
- 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)
- Prior psychological testing reports (neuropsych, personality assessment)
- 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
- Behavior/Psychomotor: Eye contact, cooperation, psychomotor agitation or retardation, abnormal movements (tardive dyskinesia screening), gait
- Speech: Rate, rhythm, volume, tone, spontaneity, latency, articulation
- Mood: Patient's subjective report in their own words
- Affect: Range, intensity, congruence with mood, lability, appropriateness to content
- Thought Process: Linear/logical, circumstantial, tangential, loose associations, flight of ideas, thought blocking, perseveration, neologisms
- Thought Content: Suicidal ideation (active/passive, plan, intent, means), homicidal ideation, delusions (type and degree of conviction), obsessions, phobias, preoccupations, overvalued ideas
- Perceptions: Hallucinations (auditory, visual, tactile, olfactory, gustatory — command hallucinations specifically), illusions, depersonalization, derealization
- Cognition: Orientation (person, place, time, situation), attention/concentration, memory (immediate, recent, remote), fund of knowledge, abstraction, calculation
- Insight: Patient's understanding of their illness and need for treatment (absent, poor, partial, good)
- Judgment: Ability to make reasonable decisions about personal safety and welfare
Step 5: Risk Assessment and Diagnostic Formulation
Risk Assessment
Conduct structured suicide risk assessment. Use the Columbia Suicide Severity Rating Scale (C-SSRS) or equivalent validated tool. Document:
- Static risk factors (prior attempts, family history of suicide, demographic risk factors)
- Dynamic risk factors (current ideation, hopelessness, substance use, recent losses, access to means)
- Protective factors (social support, reasons for living, religious beliefs, engagement with treatment, children in the home)
- Risk level determination (low, moderate, high, imminent) with clinical reasoning
Document violence risk assessment when indicated using structured professional judgment tools (HCR-20 framework).
Diagnostic Formulation
Provide DSM-5-TR diagnoses with ICD-10-CM codes. For each diagnosis, document the specific criteria met. Use the biopsychosocial formulation model:
- Biological: Genetics, medical comorbidities, substance effects, medications
- Psychological: Personality traits, coping mechanisms, cognitive patterns, trauma history
- Social: Stressors, support system, cultural factors, socioeconomic factors
Include a differential diagnosis with reasoning for each diagnosis considered and ruled out.
Checkpoint B: Post-Draft Alignment (Mandatory)
- Does the evaluation address the specific referral question?
- Are all DSM-5-TR criteria explicitly documented for each diagnosis rendered?
- Is the risk assessment documented with both risk and protective factors and a clear risk-level determination?
- Is the MSE complete across all required domains?
- Does the treatment plan logically follow from the diagnostic formulation?
Quality Audit
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.
1---2name: conducting-psychiatric-evaluations3description: Structures comprehensive psychiatric evaluation with MSE, diagnostic formulation, and risk assessment. Use when performing psychiatric assessments, documenting mental status exams, or creating diagnostic formulations.4---56# Conducting Psychiatric Evaluations78Structures comprehensive psychiatric evaluations with mental status examination, diagnostic formulation, and risk assessment in compliance with APA Practice Guidelines.910## Why This Skill Exists1112A 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.1314Regulatory 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.1516---1718## Checkpoint A: Pre-Draft Intake (Mandatory)19201. What is the clinical setting? (inpatient, outpatient, emergency department, forensic, consultation-liaison) — default: outpatient212. What is the referral question? (diagnostic clarification, medication management, risk assessment, fitness for duty) — default: diagnostic clarification223. Is this an initial evaluation or follow-up reassessment? — default: initial234. What is the patient's age group? (child/adolescent, adult, geriatric) — default: adult245. Are there known safety concerns requiring immediate risk assessment? — default: unknown, assess at intake256. What collateral sources are available? (family, prior records, referring provider notes) — default: none confirmed267. 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-7278. What is the expected output format? (narrative report, structured template, EHR-compatible note) — default: structured template2829### Documents to Request3031- Prior psychiatric evaluation reports and discharge summaries32- Current medication list including dosages and prescribing dates33- Primary care records including recent lab work (TSH, CBC, CMP, lipid panel, HbA1c)34- Prior psychological testing reports (neuropsych, personality assessment)35- School or occupational records if functional impairment is reported36- Legal records if forensic questions are involved37- Collateral statements from family members or caregivers38- Previous treatment records including therapy notes and medication trials39- Substance use treatment records including PDMP query results4041---4243## Step 1: Identifying Information and Chief Complaint4445Document 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.4647Identify 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.4849---5051## Step 2: Psychiatric and Medical History5253### History of Present Illness (HPI)54Construct 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).5556### Past Psychiatric History57Document in structured format:58- Previous diagnoses with approximate dates59- Previous hospitalizations (voluntary/involuntary, facility, length of stay, reason for admission)60- Previous medication trials with dosages, duration, response, and reason for discontinuation61- History of psychotherapy (modality, duration, response)62- History of ECT or other neuromodulation therapies63- History of suicide attempts (method, lethality, medical intervention required, precipitant)64- History of self-harm behaviors65- History of aggressive or violent behavior6667### Medical History68Document 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.6970### Substance Use History71Screen 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.7273---7475## Step 3: Social and Developmental History7677Document 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.7879Assess current functional status across domains: self-care, interpersonal relationships, occupational/academic performance, community engagement, and management of finances and legal affairs.8081---8283## Step 4: Mental Status Examination (MSE)8485Systematically document all MSE domains:8687- **Appearance:** Grooming, hygiene, attire, apparent age vs. stated age, distinguishing features, level of distress88- **Behavior/Psychomotor:** Eye contact, cooperation, psychomotor agitation or retardation, abnormal movements (tardive dyskinesia screening), gait89- **Speech:** Rate, rhythm, volume, tone, spontaneity, latency, articulation90- **Mood:** Patient's subjective report in their own words91- **Affect:** Range, intensity, congruence with mood, lability, appropriateness to content92- **Thought Process:** Linear/logical, circumstantial, tangential, loose associations, flight of ideas, thought blocking, perseveration, neologisms93- **Thought Content:** Suicidal ideation (active/passive, plan, intent, means), homicidal ideation, delusions (type and degree of conviction), obsessions, phobias, preoccupations, overvalued ideas94- **Perceptions:** Hallucinations (auditory, visual, tactile, olfactory, gustatory — command hallucinations specifically), illusions, depersonalization, derealization95- **Cognition:** Orientation (person, place, time, situation), attention/concentration, memory (immediate, recent, remote), fund of knowledge, abstraction, calculation96- **Insight:** Patient's understanding of their illness and need for treatment (absent, poor, partial, good)97- **Judgment:** Ability to make reasonable decisions about personal safety and welfare9899---100101## Step 5: Risk Assessment and Diagnostic Formulation102103### Risk Assessment104Conduct structured suicide risk assessment. Use the Columbia Suicide Severity Rating Scale (C-SSRS) or equivalent validated tool. Document:105- Static risk factors (prior attempts, family history of suicide, demographic risk factors)106- Dynamic risk factors (current ideation, hopelessness, substance use, recent losses, access to means)107- Protective factors (social support, reasons for living, religious beliefs, engagement with treatment, children in the home)108- Risk level determination (low, moderate, high, imminent) with clinical reasoning109110Document violence risk assessment when indicated using structured professional judgment tools (HCR-20 framework).111112### Diagnostic Formulation113Provide DSM-5-TR diagnoses with ICD-10-CM codes. For each diagnosis, document the specific criteria met. Use the biopsychosocial formulation model:114- **Biological:** Genetics, medical comorbidities, substance effects, medications115- **Psychological:** Personality traits, coping mechanisms, cognitive patterns, trauma history116- **Social:** Stressors, support system, cultural factors, socioeconomic factors117118Include a differential diagnosis with reasoning for each diagnosis considered and ruled out.119120---121122## Checkpoint B: Post-Draft Alignment (Mandatory)1231241. Does the evaluation address the specific referral question?1252. Are all DSM-5-TR criteria explicitly documented for each diagnosis rendered?1263. Is the risk assessment documented with both risk and protective factors and a clear risk-level determination?1274. Is the MSE complete across all required domains?1285. Does the treatment plan logically follow from the diagnostic formulation?129130---131132## Quality Audit133134- [ ] Chief complaint recorded in patient's own words135- [ ] History of present illness includes onset, duration, severity, and functional impact136- [ ] All prior medication trials documented with dosages and outcomes137- [ ] Substance use screening completed and documented138- [ ] MSE addresses all required domains with specific descriptors (not just "WNL")139- [ ] Suicide risk assessment uses structured tool (C-SSRS or equivalent)140- [ ] Protective factors documented alongside risk factors141- [ ] Each DSM-5-TR diagnosis supported by documented criteria142- [ ] Differential diagnosis explicitly addressed143- [ ] Biopsychosocial formulation included144- [ ] Treatment recommendations are specific and measurable145- [ ] Collateral sources identified and noted whether obtained or unavailable146- [ ] Cultural and linguistic factors addressed147- [ ] Informed consent for evaluation documented148- [ ] Evaluator credentials and date/time of evaluation recorded149150---151152## Guidelines1531541. Never document a diagnosis without supporting criteria — each DSM-5-TR diagnosis must reference the specific symptoms and duration thresholds met during the evaluation.1552. Always screen for suicidal ideation regardless of presenting complaint — document the screening even when negative.1563. Use direct quotes for chief complaint and key patient statements rather than paraphrasing subjective experiences.1574. Flag all [VERIFY] items for information that could not be independently confirmed during the evaluation.1585. Document medication allergies separately from intolerances (true allergy with immune response vs. side effect).1596. When cognitive concerns are present, administer and score a validated screening tool (MoCA preferred over MMSE for sensitivity to mild cognitive impairment).1607. Document the patient's decision-making capacity implicitly through the evaluation or explicitly if capacity is in question.1618. Include a clear safety plan disposition for any patient with identified suicidal ideation, regardless of assessed risk level.
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