Summary PMHNP Psychiatric Assessment and Interviewing – Exam 2 Study Guide – Psychiatric History, Communication, and Diagnostic Principles

Exam 2 Study Guide
Week 3: The Foundations of the Psychiatric History

What are elements of the psychiatric history
The psychiatric history includes:
 Chief complaint (CC)
 History of present illness (HPI)
 Psychiatric history
 Medical history
 Family psychiatric history
 Social and developmental history
 Medication history
 Substance use history
 Review of systems (ROS)
 Mental status observations

The purpose is to gather psychiatric information, formulate diagnoses, guide treatment
planning, and predict treatment response.

Alliance building and interview phases
Tasks in phases of the interview
The therapeutic alliance is the cooperative working relationship between the PMHNP and the
client. It is one of the most important goals of the psychiatric interview because trust and
rapport improve communication, adherence, and treatment outcomes. Building rapport begins
immediately during the opening phase

Interview phases
Phase 1: Opening phase
 First 5-10 minutes
 Establish rapport and trust
 Introductions and making the client comfortable
 Begin with broad/open ended questions
 Most important phase because it sets the tone for the remainder of the interview
 Tasks in the opening phase
o Introduce self and role
o Explain confidentiality
o Ensure comfort and privacy
o Begin therapeutic alliance
o Encourage client to share concerns

, Phase 2: Body of the Interview
 Approximately 30-40 minutes
 Obtain chief complaint and HPI
 Gather psychiatric, medical, family, and social history
 Explore symptoms and stressors
 Clarify symptom characteristics and timeline
 Tasks in the Body Phase
o Collect subjective and objective data
o Clarify symptoms using OLDCARTS
o Assess safety concerns
o Identify triggers/precipitants
o Explore past treatments and responses
o Develop diagnostic hypotheses

Phase 3: Closing Phase
 Final 5-10 minutes
 Summarize findings
 Clarify missing information
 Discuss diagnosis and treatment plan
 Provide education
 Arrange for follow-up care
 Tasks in the Closing Phase
o Wrap up the interview
o Provide patient education
o Discuss medication rationale and side effects
o Include client in decision-making
o Establish a follow-up appointment

Safety measures during the interview
Important safety considerations include:
 Provider should have access to the door
 Remove sharp or dangerous objects
 Have access to alarms or safety devices
 Maintain awareness of the environment
 Ensure privacy while maintaining safety
 Use a calm, non-threatening approach

The interview environment should be:
 Comfortable
 Clean