Exam 3: NR548/ NR 548 (2026/2027 Edition) Psychiatric Assessment for the PMHNP |Verified Q&A| 100% Correct- Chamberlain

Exam 3: NR548/ NR 548 (2026/2027 Edition) Psychiatric Assessment for the PMHNP |Verified Q&A| 100% Correct- Chamberlain Q. What is the digit span test? ANSWER Attention test in which a series of numbers is read to subjects and they are asked to repeat forward and backwards. No studies show good results on this test. Q. What is the SSST? ANSWER Attention test, patient is asked to count backwards from 100 by 7 until told to stop. No studies show good results on this test. Q. What is the months backward test (MBT)? ANSWER Attention test, the pt. is asked to recite the months of the year backwards. Should be able to complete in about 20 seconds. If not, strongly suggests cognitive impairment. This test has shown to be fairly sensitive. Q. What is the best way to assess attention and concentration in a pt? ANSWER Simply talk to the pt. Are they able to concentrate on the question? Can they maintain a train of thought while they answer you? If so, their attention is in tact. Q. How to conduct a mini-cog ANSWER First: ask the pt to memorize 3 simple words Second: Ask them to draw a clock showing the time 11:10. Once the clock is drawn, ask them to say back the 3 words. Q. Mini-cog scoring ANSWER A total score of 0, 1, or 2 indicates higher likelihood of clinically important cognitive impairment. A total score of 3, 4, or 5 indicates lower likelihood of dementia but does not rule out some degree of cognitive impairment. Q. Elements of the Mental Status Exam ANSWER Appearance Behavior Speech Affect Thought Process Thought Content Cognitive Examination - Includes insight & Judgement Q. Behavior Assessment ANSWER Behavior refers to how the client presents themselves during the examination. Assess eye contact, psychomotor activity (increased or decreased), movements, mannerisms, stereotypies, and posturing. Observe how the client responds to the exam. Are their responses appropriate to the topics? Can they sit still through the exam? Observe the client's gait as they walk into the office. Are their movements coordinated, slowed, or excessive? Q. Speech Assessment ANSWER Rate- Slow, fast, pressured, rhythm latency- How fast do they respond volume - High, low content- Thoughtful, articulate, rambling, vague Q. Mood ANSWER Patient's report of how they feel (Subjective) Q. Affect ANSWER Your impression of their emotional state Q. Thought Process ANSWER Thought processes involve the rate of thoughts and how they flow and are connected. Thought process is coherent vs. incoherent. Normal thought processes are linear and goal-directed. Other thought processes may be described as loose, circumstantial, or tangential. Q. Thought content ANSWER Refers to any unusual or dangerous ideas such as Suicidal Ideation Homicidal Ideation Delusions Hallucinations Q. The cognitive assessment includes: ANSWER Level of awareness or wakefulness Attention and concentration Memory Judgement Insight Q. Professional jargon should always be used when documenting what? ANSWER Thought process and thought content in psychosis. Ex. tangentiality, looseness of associations, ideas of reference. Q. Use more descriptive language in areas that? ANSWER parts of the exam that are directly relevant to the eventual diagnosis. Q. Time frame for wrapping up the interview ANSWER 10 minutes Q. All Borderline Subjects Are Tough Troubled Characters ANSWER Appearance Behavior (and attitude) Speech Affect (and mood) Thought process Thought content Cognitive examination Q. What does an MSE accomplish? ANSWER It helps make a diagnosis, especially in cases in which historical data are unreliable and allows you to create a vivid pt description for your records 3 multiple choice options Q. Appearance Qualities to Note ANSWER - Self-esteem: does the pt care about appearance? - Personal statement: does the appearance say something about the pt's interests? - Memorable aspects Q. Qualities of Speech ANSWER - Rate - Volume - Latency of response - General quality Q. Speech Terms ANSWER - Normal, thoughtful, articulate, intelligent, rapid, staccato, pressured, rambling, continuous, loud, soft, barely audible, slow, halting Q. Stability of Affect ANSWER continuum from stable affect to labile affect. Marked lability of affect is usually a marker of either mania or acute psychosis, but it may also be seen in dementia and other neuropsychiatric syndromes Q. Appropriateness of Affect ANSWER A patient who laughs uncontrollably while talking about her mother's death is exhibiting inappropriate affect, and this is useful to record. Inappropriate affect is often seen in psychosis or mania. Don't overpathologize, however; many intact people smile a bit when talking about sad things. This may reflect a defense mechanism such as denial, rather than psychosis Range of Affect Mentally healthy humans exhibit a full range of affect. At some moments they feel happy, at other moments annoyed, and at others sad. Depressed patients are said to exhibit constricted affect, and patients with schizophrenia are often said to exhibit flat affect. The problem, of course, is that many healthy people exhibit a narrow range of affect. This may be especially true during a psychiatric interview, because patients may not feel emotionally safe exposing themselves to a stranger. Thus, the diagnostic specificity of a limited range of affect is suspect and should not be overinterpreted. Intensity of Affect Intensity is often hard to distinguish from range of affect, and like range, the diagnostic specificity is unknown. The usual jargon describes three grades: intense, flat, and blunted. Flat and blunted are usually reserved for descriptions of severely depressed patients or patients with negative symptoms of schizophrenia. Intense is often used for manic or histrionic patients, but remember that many completely healthy people come across as passionate or intense. Thought Process refers to the flow of thought (coherent vs incoherent) Thought Content refers to unusual or dangerous ideas and includes SI and homicidal ideation (HI); psychotic ideation, such as delusions and hallucinations; and any significant themes that came up during the interview and relate to the psychiatric diagnosis. Elements of Cognitive Examination - Level of awareness or wakefulness - Attention and concentration - Memory - Judgment - Insight Level of Awareness or Wakefulness It will clue you in to certain diagnoses, and it will give you guidance in how to proceed with the rest of the cognitive exam *A full cognitive exam is not valid in a pt who is nodding off throughout the interview Describe the degree of sleepiness in plain English Attention and Concentration - From attentive and focused at one end to confused and distractible - The months backward test (MBT), in which you ask the patient to recite all 12 months in reverse - The best way to assess attention and concentration is simply to talk to your patient and observe how she thinks. Is she able to concentrate on your questions? Can she maintain a train of thought as she answers you? If the answer to these questions is "yes," your patient's attention is intact. Memory - You should assess both short-term memory (memory of things learned a few minutes to a few days ago) and long-term memory (memory of things learned longer than a few days ago). - Clinically valid tests of these are: (1) orientation, (2) three-object recall, (3) recall of remote personal events, and (4) recall of general cultural information Assessing Intelligence As with concentration, you can get a general idea of level of intelligence via the rest of the interview. Think of intelligence as the ability to manipulate information. High levels of educational and job attainment usually correlate with high intelligence. Wilson Rapid Approximate Intelligence Test Judgement you should assess judgment based on the material gathered throughout the interview. Did your patient decide to seek help when she felt depressed? Did she apply for unemployment benefits when she lost her job? These show good judgment. Did she decide that the best treatment for her depression was to go on a cocaine binge? This shows poor judgment. MMSE - contains 11 categories of scored questions. - The maximum possible score is 30, and scores below 30 may indicate cognitive impairment, with the precise cutoff point varying by age and education. Mini-Cog - This combines two tests: the three-item recall (of MMSE fame) and the clock-drawing task (CDT) - First, you ask your patient if you can test his memory by asking him to repeat and memorize three simple words (the specific words are up to you). Then you give him a paper and pen and ask him to draw a clock, with the hands pointing to "11:10" (or pick another time in which there is a hand on each side of the clock). Once the clock is drawn, ask him to repeat your three words. - Use the results of the three-item recall as a screen. Patients who recall all three words are not demented, those who can remember none of them are demented, whereas those who remember one or two might be demented. For patients in the middle, their performance on the CDT provides crucial information that may or may not convince you to seek neuropsychological testing. Suicidal Ideation - Suicide risk assessment is essential to evaluate the likelihood of a client attempting suicide or self-harm. - Direct terms should be used to assess suicide preoccupation and planning - it is critical to determine whether a plan exists and if the client has access to the resources needed to execute the plan - The more detailed and thorough the plan, the higher the risk. - It is important to assess whether the plan is composed of fleeting thoughts rather than action steps and whether the client is angry and lashing out or intending to bring actual harm Homicidal Ideation - assess for homicidal ideation, intent, attempts, and plans - it is critical to determine whether a plan exists and if the client has access to the resources needed to execute the plan - The more detailed and thorough the plan, the higher the risk. - It is important to assess whether the plan is composed of fleeting thoughts rather than action steps and whether the client is angry and lashing out or intending to bring actual harm Remember This Screening for suicidal and homicidal ideations is an ethical obligation of the PMHNP and is essential for protecting oneself, the client, and the public. Cognitive Assessment evaluation of a client's level of awareness, attention, concentration, and memory Mini-Cog Scoring - range is from 0-5 and is obtained from adding the 3-item recall and clock drawing scores together. - A total score of 0, 1, or 2 indicates higher likelihood of clinically important cognitive impairment. - A total score of 3, 4, or 5 indicates lower likelihood of dementia but does not rule out some degree of cognitive impairment. Essential Concepts to Educating Your Patient Briefly state your diagnosis. Find out what your patient knows about the disorder. Give a minilecture about the disorder, if indicated. Ask if there are any questions. Give your patient written educational materials. GENERAL TIPS TO HELP PATIENTS REMEMBER WHAT YOU SAY - High stress and anxiety impair memory. You might want to wait until an agitated patient calms down before talking to them about their treatment. - People recall information best if they think it is of high importance—and the corollary of this is that most people view their diagnosis as highly important and will more likely remember that than discussion of treatment options. - The first things out of your mouth are better remembered, so start your psychoeducation with what you think is the most important stuff. - Specifics are remembered better than general statements - Simple language is recalled better than complex language. - Use the "Tell-Ask-Tell" method to assess whether patients retained information and to reinforce the education. - Written instructions are better remembered than verbal instruction. I recommend keeping a notebook with you and writing down any important instructions as you are saying them, and handing your patients those instructions to bring home with them. Minilecture About the Disorder - Define the illness. Ask your patient to identify all the symptoms that he has experienced. - Define the disorder as an illness that has many symptoms, including the ones your patient has identified; try to portray it as an illness similar to the medical illnesses of diabetes or hypertension. This helps decrease the stigma associated with mental illness. - Discuss the prevalence and course of the illness. - Discuss the causes. Although we don't know the causes of most mental illnesses, you can discuss some different theories. - Discuss the options for treatment. - For medications, discuss side effect profiles and emphasize the fact that individuals experience different side effects. Over the past decade, a larger proportion of psychiatric visits have involved medication management, and we are often confronted with patients who are ambivalent about taking the treatments we prescribe. As Shea (2006) points out in his excellent book on medication adherence, a helpful trick for prodding reluctant patients into considering medications is to borrow a pediatrician's technique called "inquiry into lost dreams." As quoted in Shea's book, "I find it useful with my kids with asthma to ask them this question or a variation of it, 'Is there anything that your asthma is keeping you from doing that you really wish you could do again?' What I find with this age group is that there is often a quick answer to this question, and the answer is often related to a sport, say, football or soccer." Essential Concepts for Negotiating a Treatment Plan Elicit the patient's agenda. Negotiate a plan that you and your patient can agree on. Help the patient implement the agreed-on plan. research shows that the highest follow-up adherence rates occurred under the following circumstances The wait for follow-up appointments is short. Referrals are made to specific clinicians rather than to a clinic. Specific appointments are made at the time of disposition. The patient speaks directly to someone at the referral clinic during the evaluation session. Tips for preinterview preparation for follow ups Have an efficient system for booking your follow-up appointments. Have a list of specific clinicians who do not have excessive waiting periods for appointments. Have a list of referral clinics with their phone numbers so your patient can call and make the appointment from your office. Medication Trials 1. Determine how your patient will pay for medication. While most insurance companies pay for medications, copays vary widely, depending on what was prescribed and the generosity of the insurance company's benefits. Some patients can't afford the copays, and if so, you may be able to provide samples, depending on their availability at your clinic. 2. Make sure your patient understands the side effect profile of the medication. 3. Simplification increases recall and compliance. Thus, instead of "Take 20 mg of Prozac once a day and 50 mg of trazodone at night, as needed for insomnia," say, "Take the green capsule every morning and the white pill at night if you can't sleep." 4. Having your patient repeat what you say increases her recall of your instructions. Every write-up represents a balancing act among three objectives: 1. Thoroughness 2. Time efficiency 3. Readability Should not take more that 10-15 minutes to produce Identifying Data The identifying data should be a fairly long initial sentence that sets the stage for the entire evaluation. You want to not only identify who the patient is but also to locate her within the context of social and cultural norms. This includes age, sex, marital status, and source of referral at a minimum and may include other information such as occupation, living situation, and presence of other family. Chief Complaint a verbatim sentence of the patient's, usually in response to your question as to the reason he is seeking help. History of Present Illness History of Syndrome History of Present Crisis Past Psychiatric History (PPH) Generally, the PPH is a time to go into some detail on what sort of psychiatric treatment your patient has had in the past mnemonic Go CHa MP General statement Caregivers Hospitalizations Medication trials past Psychotherapy ROS The review of symptoms is where you can really impress your readers with your diagnostic thoroughness. Simply go through the major diagnostic categories, indicating whether the patient met any of the criteria and excluding those that you already mentioned in the HPI and in the substance abuse section, Family Hx If you draw a genogram directly on the evaluation form, this will suffice for the family psychiatric history, although you may want to add a one-line comment to highlight some facet of the history Social Hx At a minimum, your social history should include these pieces of information: Where your patient was born and raised Number of siblings Birth order of patient and siblings Who was present in the household during the formative years Educational level Work history Marital and parenting history of patient Typical daily activities other than work Medical Hx begin with a statement about the patient's general health List any illnesses, surgeries, prescribed medications, and medication allergies. Note the name of the primary care physician. If you have asked questions from the medical review of systems, note any relevant answers. At a minimum, note whether the patient has had any seizures or head injuries, both of which are often germane to psychiatric problems. Mental Status Examination In writing up or dictating the mental status section of your diagnostic evaluation, temporarily shed your clinician's mantle and become a creative writer. Describe your patient so well that a reader would be able to recognize him from your description alone. Assessment The assessment should be a brief recapitulation of the overall clinical picture and a discussion of differential diagnosis. Remember that many people who read your write-up will read only this section to get right to the point. Therefore, take pains to make the assessment both concise and informative. Treatment Plan A good, concise treatment plan should include the following: Any diagnostic testing planned (ie, neuropsychological testing, laboratory tests) Plans for medication, if you can prescribe Plans for therapy, if needed Referrals to other health care practitioners, if applicable When you plan to see your patient again How long should the interview closure be? 5-10 minutes What interval for follow up of a patient on new medication? 2 week intervals What interval for follow up of a pt stable on medication? 4 week Mental Status Exam (MSE) -best tool for establishing a psychiatric diagnosis -combination of observations, impressions, & interpretation of client responses -Eval of patients: • appearance • behavior • speech • affect • thought process • thought content • cognition mental health "a state of well-being in which every individual realizes his or her own potential, can cope with normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community" mental status -refers to emotional (feeling) and cognitive (knowing) function -functioning is inferred through assessment of an individual's behaviors: • consciousness • language • mood and affect • orientation • attention • memory • abstract reasoning • thought process • thought content • perceptions Factors that affect the interpretation of the MSE culture native language educational level literacy social factors MSE: Appearance -posture -dress -grooming -physical appearance • distinguishable markings; scars or tattoos -facial expressions level of alertness -attitudes -Self-esteem -Personal statement MSE: Behavior how the client presents themselves during the examination -eye contact -psychomotor activity • increased or decreased -movements -mannerisms -stereotypies -posturing -how the client responds to the exam • responses appropriate to topics? • sit still through exam? -gait -movements • coordinated, slowed, excessive MSE: Speech Assess general speech qualities: -rate • fast, rapidly, slowly -rhythm • monotone or slurred -latency -volume • soft, normal, or loud -content -increased or decreased pauses between questions and answers? -General quality individual who presents with an extremely rapid and pressured speech with constant interruptions may be experiencing __________ or __________ hypomania or mania An absence of speech is seen with some diagnoses such as ___________ dementia non-sensical speech is often associated with _______________ psychotic disorders MSE: Mood and Affect Mood -client's state of mind or prevalent emotional state -subjective -typically self-reported -Stable: mood is appropriate to their current situation -other: bright, happy, angry, agitated, irritable, labile, anxious, depressed, or euphoric Affect -physical manifestation of the client's emotional state as observed by the provider -normal, blunted, flat, bizarre, dysphoric, or euphoric -Qualities of affect • stability (stable or labile) • appropriateness • range (does it change with diff. situations) • intensity MSE: Thought Process -rate of thoughts and how they flow and are connected -coherent vs. incoherent -Normal: linear & goal-directed -Other: loose, circumstantial, or tangential -Clients may experience flight of ideas with little connection between thoughts or words -Assessment: questioning client, listening to responses MSE: Suicidal and Homicidal Ideation -Direct terms should be used to assess suicide preoccupation and planning -assess for homicidal ideation, intent, attempts, and plans -critical to determine whether a plan exists • access to the resources needed to execute the plan • more detailed and thorough the plan, the higher the risk • assess if plan is composed of fleeting thoughts rather than action steps • assess whether the client is angry and lashing out or intending to bring actual harm -SCREENING FOR SUICIDAL AND HOMICIDAL IDEATIONS IS AN ETHICAL OBLIGATION OF THE PMHNP & IS ESSENTIAL FOR PROTECTING ONESELF, THE CLIENT, & THE PUBLIC MSE: Cognitive Assessment -evaluation of a client's level of awareness, attention, concentration, and memory -Awareness: observation with emphasis on the client's eyes and speech -alertness or wakefulness provides information about cognitive function • help rule out potential substance use or intoxication -levels of awareness: alert and oriented, somnolent, drowsy, or even comatose -Attention and concentration: observation of responses during the interview • can they stay on topic? • able to focus and respond to Q's? • can use standardized tools such as the Mini-Mental State Exam (MMSE), digit span test and the SSST -Memory assessment: immediate recall, short-term, and long-term memory • particularly important when ruling out dementia or Alzheimer's disease • Stress, anxiety, and depression can also impact memory • orientation, three-object recall -Mini-Cog exam is commonly used to help rule out significant cognitive issues Two attention and concentration assessments digit span test -patient is given 5-7 numbers & asked to repeat them forward and backward SSST -pt asked to subtract 7 from 100 and to continue counting back by 7s until told to stop *research studies have not endorsed them -SSST given to 132 normal adults, only 42% with errorless performance -325 hospitalized psychiatric pts given SSST, no diff. in performance from 50 healthy control subjects -Digit span test among 60 elderly pts with memory impairment and 44 elderly who were healthy found no difference MMSE -Mini-Mental State Exam -30-point questionnaire -measures cognitive impairment in the areas of orientation, attention, memory, language, and visual-spatial skills -method of monitoring deterioration over time -age, education, and visual or hearing impairment may impact scores • Most studies have defined poorly educated as 8 or fewer years of education—that is, no high school -sensitivity of the test is high, specificity is low Interpret a mini-cog score (Total Possible Score: 0-5): Add the 3-item recall and clock drawing scores together. Recall Score (Total Possible Score: 0-3) -1 point for each word correctly recalled Clock Drawing Score (Total Possible Score: 0-2) -2 points for normal clock (include all numbers, 1-12) -0 points for abnormal clock -must be 2 hands present (one pointing to the 11 and one pointing to 2) -hand length not scored Mini-Cog exam -streamlined dementia screen -score range is from 0-5 -obtained from adding the 3-item recall and clock drawing scores together. -A total score of 0, 1, or 2 indicates higher likelihood of clinically important cognitive impairment -A total score of 3, 4, or 5 indicates lower likelihood of dementia • does not rule out some degree of cognitive impairment. three object recall Recall of three objects after at least 2 minutes has been shown to be a useful test in diagnosing cognitive impairments -Repeat the following three words: ball, chair, purple. -Once you are satisfied that your patient has registered all three words, say: Now I want you to remember those three words, because I'm going to ask you to repeat them in a couple of minutes. -In the meantime, ask your patient general knowledge questions bout general cultural and personal information. -Then ask him to repeat the three words. -If trouble, use the following hints: • One of them is something you can play with • One is a piece of furniture. • One is a color. General Cultural Knowledge Inability to recall at least half of these items is presumptive evidence of long-term memory impairment. -Last three presidents -famous figures • George Washington, first president • Abraham Lincoln, freed the slaves • Martin Luther King, Jr., civil rights leader • Princess Diana, British princess killed in car accident • William Shakespeare, writer • Christopher Columbus, discovered America -Famous dates • When did World War II happen? (Any time in the 1930s or 1940s is adequate.) • When was John F. Kennedy assassinated? (Sometime in the 1960s.) -Lists of information • screening for dementia is the set test: patient to name as many items (up to ten) as he can recall in each of four categories: colors, animals, fruits, and towns; max of 40, score of 25 or above excludes dx of dementia Personal Knowledge memory of remote personal events -Cognitively intact patients should be able to tell you: • Current address and phone number • Names and ages of spouse, siblings, and children • Spouse's birthday, wedding anniversary, and date and place of marriage (if married) • Parents' names and birthdays (primarily for younger patients who are not married) MSE: Insight and Judgment -final components of the mental status exam -determined to be good, limited, or poor depending on the actions the client has taken, awareness of their illness, and the plans they have for the future. Insight -client's awareness of their illness or situation Judgment -ability to anticipate the consequences of their behavior and safeguard their well-being -may be measured with a standard question but should be assessed throughout the entire interview Q's to probe for degree of insight -So, why do you think you've been having these problems? -What do you think needs to happen for your life to improve? Pt's with poor insight may respond with: -I don't know. You're the doctor. -People need to stop hassling me. (A paranoid patient.) ABSATTC Mnemonic for Elements of the Mental Status Examination -All Borderline Subjects Are Tough, Troubled Characters • Appearance • Behavior • Speech • Affect • Thought process • Thought content • Cognitive examination closure -final phase of the psychiatric interview process -provides the client with a summary and findings of the interview and allows for discussion of future plans -PMHNP may provide education during this phase final step of the psychiatric interview documentation -Thorough, accurate documentation is necessary for clinical and legal purposes Closing the Interview PMHNP explains the diagnosis and treatment options to the client -offers an opportunity for the client to ask questions and give input -discussion includes recommendations for any additional psychological assessments and laboratory testing needed -education regarding recommended medications and therapies -If a need to collaborate with other providers for information or treatment, the PMHNP should seek permission from the client at this time to do so -opportunity to address any client concerns about stigma -discuss need for F/U care Which of the following should be included when providing client education about medication regimens? Select all that apply. explain how the medication targets the symptoms, specific benefits, and expected time course. identify potential side effects, duration of side effects, and adverse effects. explain the instructions, dosing, and special requirements. use teach-back methods to ensure client understanding. explain how the medication targets the symptoms, specific benefits, and expected time course. identify potential side effects, duration of side effects, and adverse effects. explain the instructions, dosing, and special requirements. use teach-back methods to ensure client understanding. Follow-Up homework PMHNP may assign homework to the client -especially when tx plan includes cognitive-behavioral or family therapy -explain the purpose and goal of the assignment -explain whether the client will be expected to report on the homework at the next appointment Follow-Up care PMHNP should discuss the need for follow-up care with the client during the closure of the interview -include clients in determining the need for and frequency of follow-up visits • promote adherence -Two-week intervals are common when starting new medications • assess for tolerability, efficacy, and the need for dose adjustment -four-week intervals (or longer) are typical for stable clients -Scheduling future visits is important as noncompliance is common in mental health Documentation Use the ten minutes following the 50-minute interview to record clinical findings -facilitates communication with other members of the healthcare team -provides information to insurance companies and third parties for billing and reimbursement -required to satisfy legal requirements and mitigate risk • Careful and thorough record-keeping is imperative in the event of litigation All components of a clinical encounter should be documented including: • chief complaint • referral source • history of present illness • current treatments including medications and therapies • past medical, family, social histories • review of systems • mental status examination • diagnosis • treatment plan SOAP note subjective, objective, assessment, and plan method of documentation that helps organize the information from a psychiatric interview three objectives for clinical documentation -Thoroughness • thorough yet succinct description of the client mindful of presenting an accurate, objective account of the client encounter • Be aware of personal bias -Time efficiency • typically take no more than 10-15 minutes -Readability • 2-3 pages maximum to allow for easy review Identifying Data fairly long initial sentence that sets the stage for the entire evaluation -includes demographic descriptors of the client and the context of the referral • age, sex, marital status, and source of referral at a minimum • may include other information such as occupation, living situation, and presence of other family. Chief Complaint reason client gives for presenting for treatment at this time; typically, a direct quotation or subjective statement History of Present Illness -recent psychiatric symptoms, including pertinent positives and negatives -includes timeframe of recent onset or exacerbation, symptom triggers, or recent treatment and treatment changes providing a snapshot of the onset and progression of the current issue Past Psychiatric History (PPH) includes psychiatric hospitalizations, outpatient treatments, current and past medications, types of psychotherapy, and any suicide and/or violence history spanning early childhood to the present -Can use mnemonic Go CHaMP for write-up • General statement • Caregivers • Hospitalizations • Medication trials • past Psychotherapy (include if it was helpful, why/why not) Substance Use History -includes drug and alcohol use, when used, consequences of use, the recent pattern of use, last use, and treatment -also includes nicotine and caffeine usage Review of Symptoms -includes screening for present and past symptoms related to the diagnostic category -section assists in defending and confirming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5-TR) diagnosis. -go through the major diagnostic categories, indicating whether the patient met any of the criteria and excluding those that you already mentioned in the HPI and in the substance abuse section, if you have included one Family History -includes history of psychiatric disorders, substance abuse, and suicide in the client's family -provides an understanding of the client's home life, their childhood experiences, education, and relationships -genogram will suffice for family psychiatric hx Social hx At a minimum: -Where your patient was born and raised -Number of siblings -Birth order of patient and siblings -Who was present in the household during the formative years -Educational level -Work history -Marital and parenting history of patient -Typical daily activities other than work Medical History includes significant medical illnesses, hospitalizations, surgeries, seizures, head injuries with loss of consciousness, and prescribed medications and the primary care provider -may use mnemonic MIDAS -usually begin with general statement about pt's general health Mental Status Exam includes observational and direct inquiry components and requires vivid description -Describe your patient so well that a reader would be able to recognize him from your description alone Assessment -includes the diagnosis -concise and informative -A list of differential diagnoses may be included, but the initial diagnosis listed is the DSM-5 TR diagnosis. DSM-5 TR vs Diagnosis includes all diagnoses involving psychiatric, personality, or medical disorders Treatment Plan includes any diagnostic testing planned, medications, therapy, client education (dosing instructions, side effects, expected benefits, when to note efficacy), referrals, follow-up care How to Educate Your Patient -Briefly state your diagnosis -Find out what your patient knows about the disorder -Give a minilecture about the disorder, if indicated -Ask if there are any questions -Give your patient written educational materials Negotiating a Treatment Plan: Essential Concepts -Elicit the patient's agenda -Negotiate a plan that you and your patient can agree on -Help the patient implement the agreed-on plan Elicit the Patient's Agenda elicit it with a simple question, such as: How do you hope I can help you? How were you hoping that I could help you to feel better? -Sometimes patients have a pretty clear idea of what they'd like; medication, counseling, advice about something, a letter to someone -don't have a specific request or agenda; don't force the issue with these patients Negotiate a Plan treatment adherence is enhanced when the patient and practitioner agree on the nature of the problem -agree at the outset about a plan, go directly to the implementation phase -must negotiate a mutually agreed-on goal Common problematic request - patient seeks hospitalization for a problem that can be treated in an outpatient setting: What is important to keep in mind? possibility that the patient is suffering much more than originally indicated -their request for hospitalization is their way of obliquely disclosing that. -may need to reassess for SI at this point, if still satisfied that hospitalization is not indicated, discuss other options: • Day hospitalization • Respite care • Staying with a friend or relative for a while if the home situation is intolerable • Taking a few days off from work • Having the patient call you (or another clinician) for daily check-ins during a crisis period • Setting up more frequent appointments • A short course of an antianxiety medication Implementing the Agreed-On Plan likely fall into one or both of the following categories: -follow-up therapy appointment with you or someone else • highest F/U aherence: wait for F/U appt is short, referrals made to specific clinicians rather than to a clinic, specific appt made at time of disposition, pt speaks directly to someone at referral clinic during evaluation session. -Medication trial • Determine how your patient will pay for medication: Some patients can't afford the copays - if so, you may be able to provide samples • Make sure pt understands the side effect profile of the medication • Simplification increases recall and compliance • Having pt repeat what you say increases recall of instructions