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Patient Care Process for Psychiatric Assessment



  • Patient characteristics (eg, age, sex, pregnant)

  • Current medications including OTC aspirin/NSAID use, herbal products, and dietary supplements

  • Past medication history, including medications not tolerated and any allergies to medications

  • Current and past medical/psychiatric history (personal and family)

  • Social history (eg, tobacco/ethanol use) and dietary habits

  • Overall functional status

  • Objective data

    • Blood pressure (BP), heart rate (HR), respiratory rate (RR), weight

    • Labs including glucose, lipids, Complete Blood Counts (CBCs), serum drug levels, and pharmacogenetic testing results if available.

    • Psychiatric rating scales, Psychological tests, and suicide assessment


  • Cognitive and Emotional status (eg.Mental Status Examination and presence of anxiety, depression)

  • Vitals: (eg, systolic/diastolic blood pressures, heart rate, and weight (BMI))

  • Presence of physical conditions that may overlap psychiatric conditions or medication side-effects (eg, pain, nausea, vomiting, constipation, edema, tremors, headaches, dizziness, and etc.)

  • Presence of stress or possible stressors (eg, suicidality, recent surgery, pregnancy, estrogen use, and recent hospitalizations)

  • Ability/willingness to seek additional psychiatric support (eg, therapy, outpatient groups, hospitalization, and etc.)

  • Ability/willingness to follow-up with psychiatry services including medication management, psychotherapy and/or substance use disorder treatment if indicated, and primary care around medical conditions.

  • Prior medication adherence

  • Pharmacogenomics testing results


  • Drug therapy regimen including specific psychiatric medication(s), dose, route, frequency, and duration.

  • Monitoring parameters including efficacy (eg, serum drug monitoring, , pain assessment, and safety plan (eg, calling 911)

  • Patient education (eg, purpose of treatment, dietary and lifestyle modification, drug-specific information, medication administration/adherence techniques, and review results of laboratory/pharmacogenetic test results)

  • Patient education around self-monitoring for resolution of mental health symptoms, when to call the clinic with questions and concerns, and when to seek emergency medical attention (eg, suicidality).

  • Obtain release of information to obtain collateral information (eg, family members, case managers, therapists, medical providers, and etc.)

  • Send letters and/or copies of progress notes to healthcare clinicians who are also providing medications or other therapies when appropriate (eg, starting new medications, concerns about possible side-effects, and etc.).

  • Make referrals to other providers when appropriate (eg, psychologist, social worker, neurologist, pain specialist, dietician, and substance use disorder (addictions) treatment)


  • Provide verbal and written patient education regarding all elements of treatment plan

  • Use motivational interviewing and coaching strategies to maximize adherence

  • Schedule follow-up to monitor and assess medication effectiveness (eg, PHQ-9, serum drug levels), adherence assessment of all recommendations

Follow-up: Monitor and Evaluate:

  • Resolution of behavioral health symptoms (eg, utilizing rating scales at every patient care encounter)

  • Presence of adverse medication side-effects and changing medical condition status

  • Patient adherence to treatment plan using multiple sources of information (eg, medication refill records, medication administration records, serum drug levels, and etc.)

  • Re-evaluate treatment plan at least every 1-3 months. Consider scheduling early (2 weeks) or more frequent follow-up visits after starting new drug therapy or monitoring behavioral risks such as suicidality.

*Collaborate with patient, caregivers, and other health professionals



  • image Patients ...

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