How to Conduct a Comprehensive and Efficient Initial Psychiatric Evaluation
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.
Take the headache out of Psychiatric intake
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.
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.
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.
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.
Automate redundancies and save time for what matters: going more in-depth
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.
Templates for sections not included in the psychiatric intake form
Of course, some sections of a Psychiatric Evaluation Note aren't included in the intake form sent to a patient. So you’ll want to have a template that also 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).
Assessment which typically includes:
A one-liner summarizing the case.
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.
That’s the basic “recipe” for a solid psychiatric evaluation note.
Like any good recipe, clinicians can modify it to meet their specific needs.
Keep in mind when writing this note, other audiences may read it, including:
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).
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!