October 18, 2022

How to Write an Initial Psychiatric Evaluation (examples + template)

Written by

Carlene MacMillan, M.D.

I’ve met hundreds, if not thousands, of psychiatrists over the years and every single one of them visualizes their version of the “ideal psychiatric evaluation note.”

Writing these notes can be extremely time consuming with traditional word processing systems and many EHRs. Countless variations exist, but a thorough note contains similar core elements that can be streamlined if you have the right “recipe” and automations.

For example, you’re probably familiar with this workflow:

You send forms for the patient to fill out. Then, they fill it out and scan it back to you. Then you scan it into your EHR, where you can then copy and paste vital info into your assessment report. These steps take precious time for you and your patient—even if you threw away your fax machine and do it all digitally.

What should you include in your psychiatric intake?

Let’s take a look at the type of information you need collect from patients on intake forms prior to the evaluation—and how we can streamline the process:

  • Demographic information like date of birth, legal sex, gender identity, race, ethnicity, address, insurance/billing information, contact information, an emergency contact.
  • Treatment team including any medical or mental health clinicians or clinics they are under the care of.
  • Current medications including details like the reasons why the medications are prescribed.
  • Allergies.
  • Psychiatric history including information on prior mental health treatment, psychiatric hospitalizations, residential treatment or other higher levels of care, harm to self or others, and current or prior psychiatric diagnoses.
  • Past Psychiatric Medication Trials including as much details as possible. It’s helpful to provide patients with a list of categories and specific medications and to include somatic treatments like ECT and TMS as well.
  • Medical History and history of any medical hospitalizations.
  • Surgical History.
  • Substance use history including any current or prior problematic substance use.
  • Family history of psychiatric illness or pertinent medical conditions like autoimmune conditions or sudden cardiac death at a young age.
  • Social history including at least relationship status, employment history, educational history, military history, access to firearms. Social history encompasses many possible aspects. This is one section where customization based on the patient (e.g. a child vs an adult) and the specialization of the clinician come into play.
  • Ability to share any pertinent lab studies, imaging studies or other types of testing or prior evaluations, educational or medical records that would be helpful to know about.
  • A free text area for any other pertinent information the patient would like to share prior to their appointment.

What should you include in your initial psychiatric evaluation?

You’ll want to have a template that includes the following sections:

  • Chief Complaint (this can be in the patient’s own words or a brief description of why they are coming in for an evaluation).
  • History of Present Illness:
  • Medical and Psychiatric Review of Systems.
  • Mental Status Exam.
  • Pertinent Physical Exam Findings (if applicable).
  • Vital Signs.

Assessment which typically includes:
  • A one-liner summarizing the case.
  • Differential diagnosis.
  • Risk assessment.
  • Documentation of medical complexity and medical decision making to support medical necessity and the billing codes selected. If part of the assessment involved psychotherapy, be sure to document the time spent on that, the modality of therapy used and the themes covered.
  • Total face to face time.
  • Time spent not face to face but within the same day reviewing and synthesizing records, completing documentation, writing orders and talking to any pertinent sources of collateral or supervision with colleagues.

Plan which typically includes:

  • Any medication, study or lab orders and informed consent regarding them.
  • Referrals to therapy or other sources of support, including higher levels of care if indicated.
  • Plans around obtaining further collateral information or collaborating with others.
  • Timeframe for returning.
  • Documentation that how to reach the clinician in an urgent or emergent situation was discussed with the patient.

Sample Initial Psychiatric Evaluation Template

Comprehensive Psychiatric Assessment Table

1. General Information

Data Field Description
Person's Name Record the person's full name.
Date of Birth Record the person's date of birth.
Date of Visit Record the date of the visit.
Age Record the person's current age.

2. Comprehensive Assessment

Data Field Description
Comprehensive Assessment has been completed? Check Yes or No and indicate date of most recent assessment.

3. Primary Care Provider Information

Data Field Description
Primary Care Provider (PCP) Name and Credentials/ Address/ Telephone Number/Fax/Date of Last Exam Record the person’s PCP contact information. This may be an RNP or Pediatrician but must be the medical professional primarily in charge of the person’s overall physical health care.

4. Health History

Data Field Description
Physical Health History Review the Physical Health section of the Comprehensive Assessment with the person and record the date of the Comprehensive Assessment reviewed. If there is no additional pertinent physical health history, check No Additional History to be Added. If there is additional pertinent physical health history, OR if the Comprehensive Assessment was not reviewed, check Additional History/ Comments and provide the information.
Family Mental Health / Substance Use History Check all that apply or none reported and comment as necessary.
Substance Use /Addictive Behavior History Review the Substance Use/Addictive Behavior section of the Comprehensive Assessment with the person and record the date of the Comprehensive Assessment reviewed. If there is no additional pertinent substance use/addictive behavior history, check No Additional History to be Added. If there is additional pertinent substance use history, OR if Comprehensive Assessment was not reviewed: check Additional History Indicated Below and provide the information on this form in the grid below. For reporting substance use, include age of first use, date of last use, frequency, amount and method of use.

5. Treatment History

Data Field Description
Type of Service/ Mental Health or Substance Use Name of Provider/Agency/ Dates of Service/Completed (Y/N) Review the Treatment History section in the Comprehensive Assessment (mental health (MH) and substance use (SU) with the person and record the date of Comprehensive Assessment reviewed. If there is no additional pertinent treatment history, check No Additional History to be Added. If there is additional treatment information, OR if the Comprehensive Assessment has not been reviewed, check Additional History Indicated Below and provide the information on this form in the grid below. record the treatment episodes on this form in the grid below.
Additional Pertinent Information Review each area if the Assessment Domains listed in the Comprehensive Assessment and record the date of Comprehensive Assessment reviewed. For each area, if there is no additional pertinent treatment history, check No. If there is additional treatment information, OR if the Comprehensive Assessment has not been reviewed, check Yes and provide the information in Comments.

6. Mental Status Examination

Data Field Description
Mental Status Exam Avoid judgmental perceptions. Take into account cultural differences. Think of creating a picture of the person served so that anyone reading the results of the exam would be able to clearly perceive the person just as you do. Assessment items are “in the moment”, in other words as the person presents to you at the present time. There are other sections of the assessment form that address historical information.
Appearance/clothing, Eye Contact, Build, Posture, Body Movement, Behavior, Speech, Emotional State-Affect, Emotional State-Mood Check appropriate boxes for each section, taking into account culture, age, and other factors.

7. Thought and Perception

Data Field Description
Emotional State-Affect, Facial Expression, Perception, Hallucinations, Thought Content, Delusions, Other Content Check the appropriate boxes for each section.

8. Orientation, Memory, and Insight

Data Field Description
Thought Process, Intellectual Functioning, Orientation, Memory, Insight, Judgment Check the appropriate boxes for each section.
Comprehensive Assessment Table

9. Harmful Behavior Indicators

Data Field Description
Past attempts to Harm to Self or Others, Self Abuse Thoughts, Suicidal Thoughts, Aggressive Thoughts Check the appropriate boxes for each section.

10. Medication Information

Data Field Description
Other symptoms of note or information from other sources, Diagnoses/ Rationale, Medication Information, Reported side effects/adverse drug reactions/other comments on current or past medications, Does the person served have any medical conditions that require consideration in prescribing, Medication/Status/Rational and Condition/Dosage, Route, and Frequency/Amount and Refills, Explained rationale for medication choices, reviewed mixture of medications, discussed possible risks, benefits, effectiveness and alternative treatment, Laboratory Tests Ordered Provide the relevant information in each section. Check the appropriate boxes where needed.

11. Follow-Up and Signatures

Data Field Description
Follow Up Plan/Referrals, Other Psychopharmalogical Considerations to be Added to the Individualized Action Plan, Person’s/ Guardian Response to Plan, Physician/APRN/RNCS Print Name/Credentials, Supervisor – Print Name/ Credentials, Date, Physician/APRN/RNCS Signature, Supervisor Signature, Person’s Signature Provide the relevant information for each section. Signatures can be recorded where needed.

How Osmind makes Psychiatric Intake simple

With Osmind, new patients can complete online forms about their history in advance. Then that information is “automagically” imported into your evaluation note. By automating the obvious, you’ll grow to love rather than dread completing this essential documentation task.

So let’s assume you’ve gathered all the above information in advance. By automatically importing all this information into your evaluation note, you don’t don’t need to waste time typing it out again when sitting down with the patient.

Instead, you can spend time really going into depth around areas that need further elaboration. For psychiatrists, the past psychiatric history and past psychiatric medications, as well as the social history are areas where you’ll want to dive deeper to get a clear picture of how to best help your patient.

Import your patient's intake form into the eval note "automagically!"

Keep in mind when writing this note, other audiences may read it, including:

  • The patient.
  • Other colleagues working with the patient or covering for you if out.
  • Administrative staff when working on prior authorizations for medication requests.
  • Insurance companies in the event of an audit.
  • Last but not least, lawyers in the event of a lawsuit (which could be a malpractice case or something totally unrelated where the patient needs to demonstrate aspects of their mental health and medical history).

Conclusion

Evaluation notes act like a time capsule and chances are it will be referred back to as a source of truth multiple times throughout a patient’s journey within the healthcare system. In other words, it matters a lot—and having an efficient yet comprehensive workflow and templates for creating it are worth their weight in EHR gold!

Want to see how exactly Osmind makes intake easier? See: How to intake patients with Osmind, or schedule a free demo to see how to automate other common tasks in your psychiatry workflow.

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