The Psychiatric Patient Interview - Adult
Before beginning the interview ensure privacy, optimize comfort and minimize distractions.
Before starting the interview, introduce yourself:
Example Introduction:
“Hi, ____. My name is _______, a certified nurse practitioner, and I'll provide care for you
today. Is it okay if I call you _______?”
Or “Hello _____, my name is ____, and I will be your provider today.”
Additional parts of the introduction should include: “May I ask which pronouns you prefer?”
and “Can you tell me your name and date of birth?”
1. Chief Complaint (CC): The chief complaint is the reason given by the patient for
seeking medical care. The CC should be a 2-3 word description of why they are at the
office today.
You can assess this by asking: “Can you tell me why you are here today?” or “Tell me how
you are feeling right now” or “Can you share with me what brings you to the office today?”
2. History of Present Illness (HPI): Describes the course of the patient’s illness,
including when it began, the character of symptoms, the location where the symptoms
began, aggravating or alleviating factors, pertinent positives and negatives, other
related diseases, past illnesses, and surgeries or past diagnostic testing related to the
present illness. While obtaining the HPI, it is important to incorporate “OLD CARTS”.
O = Onset (Was it an acute or gradual onset? When did your symptoms begin? Did they
develop suddenly or over a period of time? Does anyone you know or have been in contact
with have similar symptoms? Are you experiencing symptoms now?)
L = location (Where is the pain or symptom located? Is it in a specific area? Does the
symptom radiate to another location?)
D = Duration (When you experience this, how long does it last? Since the symptoms began,
have they become worse? Are they intermittent?)
C = Characteristics (Describe the symptoms? Dull, sharp, intermittent? Describe how the
symptoms feel or look? Describe the sensation: stabbing, dull, aching, throbbing?)
A = Aggravating factors ( What makes it worse? What are the symptoms aggravated by?
Walking, eating, position? )
, R = Relieving factors (What makes it better? What relieves the symptoms?)
T = Treatments (What have you tried to resolve the problem? What was the response to that
treatment? Have you continued with that treatment, or if you have not, why? If you have tried
anything to manage your symptoms, what medication and dose have you taken?)
S = Severity (How severe is this? On a scale of 1-10, with ten being the most severe, can you
rate your pain?)
3. Psychiatric Review of Symptoms: This should include current symptoms typically
presenting within the past two weeks.
You can assess this by asking about:
Current anxiety symptoms (easily startled, jittery, hypervigilance, excessive worry), racing
thoughts, ruminations, panic attacks
Depression symptoms (down, depressed, hopeless), thoughts/intent/plan to harm self or
others.
Changes in sleep and appetite
Changes in mood, grandiosity or impulsivity
Changes in concentration and memory
Aggressiveness, irritability, aloofness or withdrawal.
Auditory/visual/tactile/olfactory hallucinations, fears, phobias, paranoia, or fixations
Changes in the ability to follow through with tasks, or attend to work, home, and school
obligations
Changes in self-care routines, hygiene
4. Psychiatric History: This should include past data and any current data not
addressed previously.
You can assess this by asking about
Past and current psychiatric diagnoses.
Prior psychotic or aggressive ideas, including thoughts of physical or sexual aggression or
homicide.
Prior aggressive behaviors (e.g., homicide, domestic or workplace violence, other physically
or sexually aggressive threats or acts).
Before beginning the interview ensure privacy, optimize comfort and minimize distractions.
Before starting the interview, introduce yourself:
Example Introduction:
“Hi, ____. My name is _______, a certified nurse practitioner, and I'll provide care for you
today. Is it okay if I call you _______?”
Or “Hello _____, my name is ____, and I will be your provider today.”
Additional parts of the introduction should include: “May I ask which pronouns you prefer?”
and “Can you tell me your name and date of birth?”
1. Chief Complaint (CC): The chief complaint is the reason given by the patient for
seeking medical care. The CC should be a 2-3 word description of why they are at the
office today.
You can assess this by asking: “Can you tell me why you are here today?” or “Tell me how
you are feeling right now” or “Can you share with me what brings you to the office today?”
2. History of Present Illness (HPI): Describes the course of the patient’s illness,
including when it began, the character of symptoms, the location where the symptoms
began, aggravating or alleviating factors, pertinent positives and negatives, other
related diseases, past illnesses, and surgeries or past diagnostic testing related to the
present illness. While obtaining the HPI, it is important to incorporate “OLD CARTS”.
O = Onset (Was it an acute or gradual onset? When did your symptoms begin? Did they
develop suddenly or over a period of time? Does anyone you know or have been in contact
with have similar symptoms? Are you experiencing symptoms now?)
L = location (Where is the pain or symptom located? Is it in a specific area? Does the
symptom radiate to another location?)
D = Duration (When you experience this, how long does it last? Since the symptoms began,
have they become worse? Are they intermittent?)
C = Characteristics (Describe the symptoms? Dull, sharp, intermittent? Describe how the
symptoms feel or look? Describe the sensation: stabbing, dull, aching, throbbing?)
A = Aggravating factors ( What makes it worse? What are the symptoms aggravated by?
Walking, eating, position? )
, R = Relieving factors (What makes it better? What relieves the symptoms?)
T = Treatments (What have you tried to resolve the problem? What was the response to that
treatment? Have you continued with that treatment, or if you have not, why? If you have tried
anything to manage your symptoms, what medication and dose have you taken?)
S = Severity (How severe is this? On a scale of 1-10, with ten being the most severe, can you
rate your pain?)
3. Psychiatric Review of Symptoms: This should include current symptoms typically
presenting within the past two weeks.
You can assess this by asking about:
Current anxiety symptoms (easily startled, jittery, hypervigilance, excessive worry), racing
thoughts, ruminations, panic attacks
Depression symptoms (down, depressed, hopeless), thoughts/intent/plan to harm self or
others.
Changes in sleep and appetite
Changes in mood, grandiosity or impulsivity
Changes in concentration and memory
Aggressiveness, irritability, aloofness or withdrawal.
Auditory/visual/tactile/olfactory hallucinations, fears, phobias, paranoia, or fixations
Changes in the ability to follow through with tasks, or attend to work, home, and school
obligations
Changes in self-care routines, hygiene
4. Psychiatric History: This should include past data and any current data not
addressed previously.
You can assess this by asking about
Past and current psychiatric diagnoses.
Prior psychotic or aggressive ideas, including thoughts of physical or sexual aggression or
homicide.
Prior aggressive behaviors (e.g., homicide, domestic or workplace violence, other physically
or sexually aggressive threats or acts).
