Initial Psychiatric Initial Psychiatric AssessmentsAssessments

Teresa Chahine MSN, PMHNPTeresa Chahine MSN, PMHNPOakland University, School of Oakland University, School of

NursingNursing

Components of Components of Mental Health HistoryMental Health History

Patient IdentificationPatient Identification Chief ComplaintChief Complaint Associated Symptoms Affecting Associated Symptoms Affecting

FunctioningFunctioning History of Presenting IllnessHistory of Presenting Illness

Past Psychiatric HistoryPast Psychiatric History Substance Use HistorySubstance Use History

Medical-Surgical HistoryMedical-Surgical History Social HistorySocial History Mental Status ExaminationMental Status Examination Safety AlertsSafety Alerts

Patient IdentificationPatient Identification

NameName AgeAge GenderGender RaceRace AddressAddress Emergency ContactEmergency Contact Guardianship Guardianship

StatusStatus Legal HistoryLegal History

Evaluation StatusEvaluation Status VoluntaryVoluntary PetitionedPetitioned Court OrderCourt Order Modified Court OrderModified Court Order

Insurance Insurance CoverageCoverage

Living SituationLiving Situation Source of IncomeSource of Income AllergiesAllergies

Chief ComplaintChief Complaint

What does the client see as the presenting What does the client see as the presenting problem.problem.

Critical Characteristics:Critical Characteristics: OnsetOnset PrecipitantsPrecipitants Aggravating factors/StressorsAggravating factors/Stressors DurationDuration SeveritySeverity Associated symptomsAssociated symptoms What relieves symptoms/coping strategiesWhat relieves symptoms/coping strategies Patient’s understanding of problemPatient’s understanding of problem

Associated SymptomsAssociated Symptoms

Self Harm*Self Harm* Aggression/AgitationAggression/Agitation Violence towards othersViolence towards others Impulsivity*Impulsivity* Hopelessness*Hopelessness* HelplessnessHelplessness Activities of Daily LivingActivities of Daily Living Social CircumstancesSocial Circumstances Work PerformanceWork Performance

Anxiety*Anxiety* Panic Attacks*Panic Attacks* AnhedoniaAnhedonia PsychosisPsychosis Emotional StateEmotional State Coping StrategiesCoping Strategies Appetite Appetite Sleep DisturbanceSleep Disturbance

Global Insomnia*Global Insomnia*

* These symptoms are directly correlated to suicide risk factors.

Level of FunctioningLevel of Functioning

Activities of Daily Activities of Daily LivingLiving Ability to bathe, etcAbility to bathe, etc Adhere to treatmentAdhere to treatment Attend to houseworkAttend to housework Maintain Maintain

EmploymentEmployment HobbiesHobbies SocializationSocialization

AppearanceAppearance Physical Physical

CharacteristicsCharacteristics DressDress GroomingGrooming HygieneHygiene Eye ContactEye Contact Facial ExpressionFacial Expression

History of Presenting History of Presenting IllnessIllness

Past Psychiatric HxPast Psychiatric Hx Current TreatmentCurrent Treatment Current MedicationsCurrent Medications Onset of illnessOnset of illness HospitalizationsHospitalizations History of AdherenceHistory of Adherence History of Trauma:History of Trauma:

Child AbuseChild Abuse RapeRape Domestic ViolenceDomestic Violence

Family Psychiatric Family Psychiatric HistoryHistory

Past Addiction HxPast Addiction Hx Current UseCurrent Use Current TreatmentCurrent Treatment History of WithdrawalsHistory of Withdrawals

DTsDTs SeizuresSeizures

Onset of UseOnset of Use Periods of SobrietyPeriods of Sobriety History of TreatmentHistory of Treatment Family Addiction Family Addiction

HistoryHistory

Medical-Surgical HistoryMedical-Surgical History

Serious or Chronic IllnessesSerious or Chronic Illnesses Current MedicationsCurrent Medications Recent HospitalizationsRecent Hospitalizations SurgeriesSurgeries InjuriesInjuries AllergiesAllergies

Social HistorySocial History Living SituationLiving Situation RelationshipsRelationships

Marital Status Marital Status Current RelationshipCurrent Relationship Longest RelationshipLongest Relationship

Family StructureFamily Structure Support SystemSupport System

EducationalEducational Occupation/Work HistoryOccupation/Work History Financial SupportFinancial Support Ethnic or Spiritual Issues (if apply)Ethnic or Spiritual Issues (if apply)

Mental Status ExamMental Status Exam

LethalityLethality Self HarmSelf Harm Assaultive BehaviorAssaultive Behavior Destruction to Destruction to

PropertyProperty Mood & AffectMood & Affect Speech PatternSpeech Pattern Thought PatternThought Pattern

OrientationOrientation Thought ContentThought Content MemoryMemory HallucinationsHallucinations DelusionsDelusions InsightInsight JudgmentJudgment

Please give specific examples and quote client’s statements.

Safety AlertsSafety Alerts

Medical conditions requiring Medical conditions requiring immediateimmediate treatment.treatment.

Active alcohol or benzodiazapine Active alcohol or benzodiazapine intoxication or withdrawal.intoxication or withdrawal.

Actively psychotic with command Actively psychotic with command hallucinations.hallucinations.

Actively suicidal or homicidal with Actively suicidal or homicidal with intent.intent.

Dependent children suspected of being Dependent children suspected of being neglected or abused by client. neglected or abused by client.

Special Considerations:Special Considerations:

Pre-teen and TeensPre-teen and TeensAges 8-17Ages 8-17

Suicidal AssessmentSuicidal Assessment Substance Abuse/DependenceSubstance Abuse/Dependence Attention-Deficit and Disruptive Attention-Deficit and Disruptive

Behavior DisordersBehavior Disorders Tic DisordersTic Disorders Communication DisordersCommunication Disorders Learning/Developmental DisordersLearning/Developmental Disorders Elimination DisordersElimination Disorders

ImpressionImpression

Summary of data which supports the Summary of data which supports the documented diagnoses.documented diagnoses.

Axis I through V Axis I through V Severity of illness and intensity of Severity of illness and intensity of

care.care. Plan of carePlan of care Nursing interventions and outcomes.Nursing interventions and outcomes. Disposition (referrals)Disposition (referrals)

Multiaxial SystemMultiaxial System Axis IAxis I Clinical DisordersClinical Disorders

--Other conditions that may be a Other conditions that may be a focus of clinical attention.focus of clinical attention.

Axis IIAxis II Personality DisordersPersonality DisordersMental RetardationMental Retardation

Axis IIIAxis III General Medical ConditionsGeneral Medical Conditions Axis IVAxis IV Psychosocial and Environmental Psychosocial and Environmental

ProblemsProblems Axis VAxis V Global Assessment of Global Assessment of

FunctioningFunctioning

Axis IV: Psychosocial and Axis IV: Psychosocial and Environmental ProblemsEnvironmental Problems

Primary Support GroupPrimary Support Group Social EnvironmentSocial Environment EducationEducation OccupationalOccupational HousingHousing EconomicEconomic Access to Health CareAccess to Health Care Interaction with legal/criminal systemInteraction with legal/criminal system Other psychosocial/environmental Other psychosocial/environmental

problemsproblems

GGlobal Assessment of lobal Assessment of FunctioningFunctioning (GAF) (GAF)

100-91 life’s problems never seem to get out of hand 90-81 good functioning in all areas, no more than

everyday issues 80-71 transient and expectable reactions to psycho-social

stressors 70-61 mild symptoms 60-51 moderate symptoms 50-41 Serious symptoms 40-31 unable to work, major impairment in several areas 30-21 Behavior is considerably influenced by delusions or

hallucinations OR serious impairment in communication or judgment

20-11 danger of hurting self or others without clear expectations of death.

10-1 Persistent danger of severely hurting self or others

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