NR548 Psychiatric Assessment Week 4
Questions and Answers
1. Psychiatric History components include:: - chief complaint
-history of the present illness (HPI)
-psychiatric history
-medical history
-family history
-social and developmental history
2. 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.
3. 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.
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8
, 4. 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 ettects.
-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.
5. 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.
2/
8
Questions and Answers
1. Psychiatric History components include:: - chief complaint
-history of the present illness (HPI)
-psychiatric history
-medical history
-family history
-social and developmental history
2. 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.
3. 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.
1/
8
, 4. 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 ettects.
-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.
5. 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.
2/
8
