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KEY CONCEPTS

KEY CONCEPTS

  • Image not available. Patients with psychiatric conditions are treated in all healthcare settings. All clinicians can apply the basic skills of the psychiatric assessment to provide the best care for patients.

  • Image not available. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the Pocket Guide to the DSM-5 Diagnostic Exam provides clinicians with a standardized approach for the initial assessment and follow-up of patients with psychiatric conditions.

  • Image not available. The World Health Organization's International Classification of Diseases and Related Health Problems (ICD) classification is currently used in all patient care settings for billing purposes.

  • Image not available. Clinicians should be prepared to gather both the psychiatric and physical health history from their patients. Obtaining a release of information (ROI) from patients to communicate with other healthcare providers or significant others is often necessary when sharing protected health information (PHI).

  • Image not available. Patient interviews should be conducted in an atmosphere that ensures the comfort, privacy, and safety of both the patient and the clinician. Effective listening skills and the application of open-ended questions are essential in the interview process and therapeutic relationship. Motivational interviewing (MI) can empower patients to participate and design achievable treatment goals.

  • Image not available. If a patient is in crisis, the clinician may feel some apprehension about asking certain assessment questions. Knowing what specific questions to ask can help facilitate inquiry about sensitive areas, such as delusional thinking and suicidality.

  • Image not available. Current and past medication histories, including allergies, side effects, and clinical response are the cornerstone of effective medication management. The medication history should be assessed for safety (eg, contraindications and drug interactions), tolerability (eg, side effects), efficacy (eg, response of target symptoms and adequate dosage and duration), and adherence (eg, affordability).

  • Image not available. Baseline mental status examination (MSE), psychiatric rating scales, and psychological/neuropsychological tests are useful tools in diagnosing and monitoring the severity of symptoms and response to treatments of psychiatric disorders.

  • Image not available. Although there are no diagnostic tests for psychiatric disorders, physical and laboratory assessments can help rule out drug-induced or medical causes that may produce similar or overlapping symptoms.

  • Image not available. Psychiatric rating scales, cognitive testing (neuropsychiatric rating scales), and psychological testing provide objective measures of psychiatric symptoms, adverse side effects, memory, and intellectual capacity and are often used in research and clinical settings.

PATIENT CARE PROCESS

Patient Care Process for the Psychiatric Assessment

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Collect

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

  • Current medications including over-the-counter (OTC) aspirin/ nonsteroidal anti-inflammatory drugs (NSAIDs) 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 (see Table e79-1)

  • 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 (see Tables e79-2 to e79-6)

Assess

  • Cognitive and Emotional status (eg, Mental Status Examination ...

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