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KEY CONCEPTS

KEY CONCEPTS

  • image Patients with psychiatric conditions are treated in all healthcare settings. All clinicians should apply the basic principles of the psychiatric assessment to provide the best care.

  • image 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 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 Clinicians should be prepared to gather both psychiatric and physical health histories 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 Patient interviews should be conducted in an atmosphere that ensures the comfort and privacy of both the patient and the clinician. Effective listening skills and the application of open-ended questions are essential in the interview process and for building a therapeutic relationship. Motivational interviewing can empower patients to participate and help design achievable treatment goals.

  • image 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 Current and past medication histories, including allergies, adverse effects, and clinical response are cornerstones of effective medication management. The medication history should be assessed for safety (eg, contraindications and medication interactions), tolerability (eg, adverse effects), efficacy (eg, response of target symptoms and adequate dosage and duration), and adherence (eg, affordability and the ability to take medications as prescribed).

  • image 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 Although there are no diagnostic tests for psychiatric disorders, physical and laboratory assessments can help rule out substances, medications, or medical conditions that may produce similar or overlapping symptoms.

  • image Psychiatric rating scales, cognitive testing, and psychological testing provide objective measures of psychiatric symptoms, adverse effects, memory, and intellectual capacity and are often used in research and clinical settings.

BEYOND THE BOOK

BEYOND THE BOOK

Watch the following videos to learn about the mental status examination (MSE) and build your knowledge of the MSE which is an assessment commonly used in psychiatry. The “Objective” component of the S.O.A.P. acronym S (Subjective), O (Objective), A (Assessment), and P (Plan) is used to describe the physical examination in the field of medicine. In contrast, psychiatry uses the MSE as the “Objective” component to describe the patient’s appearance, concentration, thoughts, and feelings. Understanding the MSE can help you identify target symptoms for psychiatric pharmacotherapy. Try completing a practice MSE on a simulated patient.

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