NR548 Psychiatric Assessment Week 4
Psychiatric History components include:
• chief complaint
• history of the present illness (HPI)
• psychiatric history
• medical history
• family history
• social and developmental history
Chief Complaint
• Verbatim statement of the client's reason for seeking treatment or
evaluation.
• Using the client's own words to document the chief complaint, even if
improbable or nonsensical, conveys valuable information about the client's
capacity for self-observation and insight.
History of present illness (HPI)
• A concise, clear, chronological description of the chief complaint.
• The HPI details what the client believes to be causing the present
symptoms.
• The HPI includes recent psychiatric symptoms, including both pertinent
positives and negatives.
• To be diagnostically useful, symptom characteristics should be described in
detail.
• The provider should gather information about the timeframe of symptom
onset or exacerbation, triggers or stressful life events, and recent treatment
and treatment changes. Information about the nature of the symptoms,
when they emerged, and how they have progressed is essential.
Psychiatric History
• Describes previous episodes of mental health symptoms, whether treated or
not.
• The history should detail the initial onset of symptoms and progress
chronologically to the current episode.
• Symptom characteristics and progression should be described in detail.
, • If the client has taken psychiatric medication in the past, the psychiatric
history should note which drug(s) have been prescribed, the dosage and
length of treatment, and the client's response to treatment.
• The provider should note which medications have been therapeutic and
whether the client experienced adverse effects.
• If the client has received psychotherapy, the PMHNP should note which
therapy modality was used, the frequency and length of therapy, and any
benefits the client experienced.
• Previous psychiatric hospitalizations should be noted, as should past suicide
attempts, ideation, or episodes of self-harm.
Medical History
• A thorough, accurate medical history helps inform the psychiatric interview.
• The past medical history (PMH) encompasses information about all current
and past medical conditions from childhood and adulthood including
physical, surgical, psychiatric, and obstetric/gynecologic health history, and
health maintenance.
• A major medical illness or surgery may precipitate a psychiatric disturbance
while underlying medical conditions will inform diagnosis and treatment
decisions.
• The PMHNP should obtain the name and dosing schedule for all currently
prescribed medications to avoid the risk of adverse interactions with new
psychiatric prescriptions.
• Similarly, client use of tobacco, alcohol, or other substances should be
detailed.
• The PMHNP should conduct a brief review of systems (ROS).
Medical diagnoses may present with psychiatric symptoms, including but not limited to:
• hyperthyroidism: anxiety, panic attacks, and mood swings
• hypothyroidism: depression, difficulty sleeping, and loss of appetite
• diabetes: mood disturbances
• chronic pain: depression, anxiety, poor sleep
• serious or terminal illnesses such as cancer or chronic autoimmune disorders:
anxiety and depression
Family psychiatric history
• Many psychiatric disorders have a genetic component.
Psychiatric History components include:
• chief complaint
• history of the present illness (HPI)
• psychiatric history
• medical history
• family history
• social and developmental history
Chief Complaint
• Verbatim statement of the client's reason for seeking treatment or
evaluation.
• Using the client's own words to document the chief complaint, even if
improbable or nonsensical, conveys valuable information about the client's
capacity for self-observation and insight.
History of present illness (HPI)
• A concise, clear, chronological description of the chief complaint.
• The HPI details what the client believes to be causing the present
symptoms.
• The HPI includes recent psychiatric symptoms, including both pertinent
positives and negatives.
• To be diagnostically useful, symptom characteristics should be described in
detail.
• The provider should gather information about the timeframe of symptom
onset or exacerbation, triggers or stressful life events, and recent treatment
and treatment changes. Information about the nature of the symptoms,
when they emerged, and how they have progressed is essential.
Psychiatric History
• Describes previous episodes of mental health symptoms, whether treated or
not.
• The history should detail the initial onset of symptoms and progress
chronologically to the current episode.
• Symptom characteristics and progression should be described in detail.
, • If the client has taken psychiatric medication in the past, the psychiatric
history should note which drug(s) have been prescribed, the dosage and
length of treatment, and the client's response to treatment.
• The provider should note which medications have been therapeutic and
whether the client experienced adverse effects.
• If the client has received psychotherapy, the PMHNP should note which
therapy modality was used, the frequency and length of therapy, and any
benefits the client experienced.
• Previous psychiatric hospitalizations should be noted, as should past suicide
attempts, ideation, or episodes of self-harm.
Medical History
• A thorough, accurate medical history helps inform the psychiatric interview.
• The past medical history (PMH) encompasses information about all current
and past medical conditions from childhood and adulthood including
physical, surgical, psychiatric, and obstetric/gynecologic health history, and
health maintenance.
• A major medical illness or surgery may precipitate a psychiatric disturbance
while underlying medical conditions will inform diagnosis and treatment
decisions.
• The PMHNP should obtain the name and dosing schedule for all currently
prescribed medications to avoid the risk of adverse interactions with new
psychiatric prescriptions.
• Similarly, client use of tobacco, alcohol, or other substances should be
detailed.
• The PMHNP should conduct a brief review of systems (ROS).
Medical diagnoses may present with psychiatric symptoms, including but not limited to:
• hyperthyroidism: anxiety, panic attacks, and mood swings
• hypothyroidism: depression, difficulty sleeping, and loss of appetite
• diabetes: mood disturbances
• chronic pain: depression, anxiety, poor sleep
• serious or terminal illnesses such as cancer or chronic autoimmune disorders:
anxiety and depression
Family psychiatric history
• Many psychiatric disorders have a genetic component.
