CMN548 unit 1: Psychiatric history and psychiatric
assessment
, 1) Identifying data: pt name.sex/,arital status/race/ethnicity/occupation.
2) Source and reliability: Where information is coming from
(patient/chart/family) how reliable information is- use own judgment
3) Chief Complaint: Pts own statement of why they are here>
4) HPI History of present illness: chronological description of current
episode include changes in habits/interests/physical health/relationships.
Length of time /fluctuations in severity/stressors involved.
What alleviates symptoms, triggering factors-why now? Any interventions
(therapy/medications tried).
Include Psychiatric Review of Systems:
Mood/anxiety/psychosis/other
Mood- depressive symptoms- sadness/tearfulness/difficulty concentrating
sleep/appetite.
USE SIGECAPS
S- Sleep
I-Interest
G-Guilt
E-Energy
C-Concentration
A-Appetite
P- psychomotor agitation/slowing
S- Suicidality
Mood-Mania impulsivity/reckless behavior/grandiosity/decreased need for
sleep/excessive spending/hyper-sexuality, talkativeness/racing thoughts /excessive
energy
Mood-mixed: irritability/liability
ANXIETY
Generalized anxiety sx
( where when who/how long/how frequent
Panic D/O-
somatic sx, agoraphobic, SOB, trouble swallowing/sense of doom
OCD symptoms:
checking/rituals/organizing rational vs irrational beliefs
PTSD:
nightmares, startle response/flashbacks/avoidance
Social Anxiety Symptoms/Simple phobias
Psychosis
Hallucinations
- Auditory/visual olfactory/tactile
Paranoia
Delusions
assessment
, 1) Identifying data: pt name.sex/,arital status/race/ethnicity/occupation.
2) Source and reliability: Where information is coming from
(patient/chart/family) how reliable information is- use own judgment
3) Chief Complaint: Pts own statement of why they are here>
4) HPI History of present illness: chronological description of current
episode include changes in habits/interests/physical health/relationships.
Length of time /fluctuations in severity/stressors involved.
What alleviates symptoms, triggering factors-why now? Any interventions
(therapy/medications tried).
Include Psychiatric Review of Systems:
Mood/anxiety/psychosis/other
Mood- depressive symptoms- sadness/tearfulness/difficulty concentrating
sleep/appetite.
USE SIGECAPS
S- Sleep
I-Interest
G-Guilt
E-Energy
C-Concentration
A-Appetite
P- psychomotor agitation/slowing
S- Suicidality
Mood-Mania impulsivity/reckless behavior/grandiosity/decreased need for
sleep/excessive spending/hyper-sexuality, talkativeness/racing thoughts /excessive
energy
Mood-mixed: irritability/liability
ANXIETY
Generalized anxiety sx
( where when who/how long/how frequent
Panic D/O-
somatic sx, agoraphobic, SOB, trouble swallowing/sense of doom
OCD symptoms:
checking/rituals/organizing rational vs irrational beliefs
PTSD:
nightmares, startle response/flashbacks/avoidance
Social Anxiety Symptoms/Simple phobias
Psychosis
Hallucinations
- Auditory/visual olfactory/tactile
Paranoia
Delusions
