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Patient Care Process for Psychiatric Assessment
Collect:
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
Assess:
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
Plan:*
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)
Implement:*
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
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KEY CONCEPTS
Patients ...