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Initial Psychiatric Evaluation Template: A Comprehensive Guide for Professionals
Introduction:
Navigating the complexities of a first psychiatric evaluation can be daunting, even for seasoned professionals. A well-structured initial psychiatric evaluation template is crucial for ensuring a thorough assessment, efficient documentation, and ultimately, the best possible care for your patient. This comprehensive guide provides a detailed look at creating and utilizing such a template, covering key elements, legal considerations, and best practices. We'll move beyond simple checklists and delve into the nuances of building a truly effective tool for your practice. This post offers not just a sample template, but a framework for building your own personalized and compliant document.
H2: Key Components of an Effective Initial Psychiatric Evaluation Template
A robust initial psychiatric evaluation template isn't just a checklist; it's a structured framework guiding a comprehensive assessment. Here's what it should include:
H3: Identifying Information and Presenting Problem:
This section should clearly state the patient's demographic information (name, date of birth, contact information), the date of the evaluation, and a concise but informative description of the reason for the evaluation—the presenting problem. This should be in the patient's own words whenever possible, maintaining accuracy and avoiding assumptions.
H3: History of Presenting Illness (HPI):
The HPI forms the core of the evaluation. It explores the timeline, severity, and characteristics of the patient's symptoms. Use open-ended questions to encourage detailed responses and explore symptom triggers, duration, frequency, and impact on daily functioning. Consider using standardized scales where appropriate (e.g., PHQ-9 for depression, GAD-7 for anxiety).
H3: Past Psychiatric History:
This section should detail previous diagnoses, treatments (including medications, therapy types, and hospitalizations), and responses to previous interventions. Include information about any past suicidal or self-harm behaviors. This is crucial for establishing a baseline and understanding the patient's treatment trajectory.
H3: Substance Use History:
A thorough assessment of substance use is essential. Document the type, frequency, amount, and duration of any substance use, as well as any history of substance use disorder. Utilize standardized screening tools where applicable (e.g., AUDIT-C for alcohol).
H3: Medical History:
Document any relevant medical conditions, including current medications, allergies, and significant past medical events. This information is crucial in understanding potential interactions and contributing factors to the patient's mental health.
H3: Social History:
Gather information about the patient's social support system, family dynamics, employment history, housing situation, and any significant life stressors. This helps contextualize the patient's mental health within their broader life circumstances.
H3: Mental Status Examination (MSE):
The MSE is a snapshot of the patient's current mental state. It includes observations of appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment. This section requires careful observation and detailed recording.
H3: Diagnostic Impression:
Based on the information gathered, formulate a diagnostic impression using the DSM-5 or ICD-11 criteria. Be precise and justify your diagnosis with specific observations and findings from the evaluation.
H3: Treatment Plan:
Outline a clear and concise treatment plan, including medication recommendations (if applicable), psychotherapy suggestions, and any other necessary interventions. Discuss the patient's involvement in the treatment planning process and their agreement with the plan.
H2: Legal and Ethical Considerations
Your initial psychiatric evaluation template must adhere to all relevant legal and ethical guidelines. Ensure patient confidentiality (HIPAA compliance in the US), obtain informed consent, and document all interactions accurately and objectively. Maintain clear and concise language, avoiding subjective interpretations. Consult with legal counsel if needed to ensure compliance with specific jurisdictional regulations.
H2: Creating Your Own Customized Template
While this guide provides a comprehensive framework, you'll likely need to customize your template to best suit your practice’s specific needs and patient population. Consider using electronic health record (EHR) software for efficient documentation and data management. Regularly review and update your template to reflect changes in clinical best practices and legal requirements.
Conclusion:
A well-designed initial psychiatric evaluation template is a cornerstone of effective mental healthcare. By following the guidelines outlined above and customizing the template to your needs, you can ensure thorough assessments, accurate documentation, and ultimately, better outcomes for your patients. Remember that ongoing professional development and staying updated on best practices are essential in this constantly evolving field.
FAQs:
1. Can I use a generic template online? While readily available templates can provide a starting point, it's crucial to tailor them to meet specific legal and ethical requirements and clinical needs. Always adapt them to your practice and patient population.
2. How often should I review and update my template? Regular review (at least annually) is recommended, incorporating updated diagnostic criteria, best practices, and legal changes.
3. What software is best for creating and managing my psychiatric evaluation template? EHR software is generally preferred for its integration capabilities, security, and efficient data management. Explore different options based on your practice's requirements.
4. What if I don't know the DSM-5 criteria thoroughly? Continuous learning is crucial. Use reliable resources like the DSM-5 itself, clinical textbooks, and continuing education opportunities to improve your diagnostic skills.
5. Is it essential to use standardized rating scales? While not always mandatory, standardized scales enhance the objectivity and reliability of your assessments, aiding in tracking progress and treatment effectiveness. They offer a quantitative measure that complements your clinical observations.
| initial psychiatric evaluation template: Diagnostic and Statistical Manual of Mental Disorders (DSM-5) American Psychiatric Association, 2021-09-24 |
| initial psychiatric evaluation template: The Psychiatric Interview Daniel J. Carlat, 2005 Revised and updated, this practical handbook is a succinct how-to guide to the psychiatric interview. In a conversational style with many clinical vignettes, Dr. Carlat outlines effective techniques for approaching threatening topics, improving patient recall, dealing with challenging patients, obtaining the psychiatric history, and interviewing for diagnosis and treatment. This edition features updated chapters on the major psychiatric disorders, new chapters on the malingering patient and attention-deficit hyperactivity disorder, and new clinical vignettes. Easy-to-photocopy appendices include data forms, patient education handouts, and other frequently referenced information. Pocket cards that accompany the book provide a portable quick-reference to often needed facts. |
| initial psychiatric evaluation template: Psychotherapy for the Advanced Practice Psychiatric Nurse Kathleen Wheeler, PhD, PMHNP-BC, APRN, FAAN, 2020-09-10 The leading textbook on psychotherapy for advanced practice psychiatric nurses and students Award-winning and highly lauded, Psychotherapy for the Advanced Practice Psychiatric Nurse is a how-to compendium of evidence-based approaches for both new and experienced advanced practice psychiatric nurses and students. This expanded third edition includes a revised framework for practice based on new theory and research on attachment and neurophysiology. It advises the reader on when and how to use techniques germane to various evidence-based psychotherapy approaches for the specific client problems encountered in clinical practice. This textbook guides the reader in accurate assessment through a comprehensive understanding of development and the application of neuroscience to make sense of what is happening for the patient in treatment. Contributed by leaders in the field, chapters integrate the best evidence-based approaches into a relationship-based framework and provides helpful patient-management strategies, from the first contact through termination. This gold-standard textbook and reference honors the heritage of psychiatric nursing, reaffirms the centrality of relationship for psychiatric advanced practice, and celebrates the excellence, vitality, depth, and breadth of knowledge of the specialty. New to This Edition: Revised framework for practice based on new theory and research on attachment and neurophysiology New chapters: Trauma Resiliency Model Therapy Psychotherapeutics: Re-uniting Psychotherapy and Psychopharmacotherapy Trauma-Informed Medication Management Integrative Medicine and Psychotherapy Psychotherapeutic Approaches with Children and Adolescents Robust instructor resources Key Features: Offers a how to of evidence-based psychotherapeutic approaches Highlights the most-useful principles and techniques of treatment for nurse psychotherapists and those with prescriptive authority Features guidelines, forms, and case studies to guide treatment decisions Includes new chapters and robust instructor resources—chapter PowerPoints, case studies, and learning activities |
| initial psychiatric evaluation template: Handbook of Geropsychiatry for the Advanced Practice Nurse Leigh Powers, DNP, MSN, MS, APRN, PMHNP-BC, 2020-12-28 Offers a wealth of information and insight geared specifically for APRNs providing holistic mental health care to older adults Addressing the most commonly-encountered mental health disorders, this practical, evidence-based resource for advanced practice nurses, nurse educators, and graduate nursing students delivers the knowledge and tools needed to effectively assess, examine, diagnose, treat, and promote optimal mental health in the geriatric patient. Written by recognized experts in the field of geropsychiatry, this handbook encompasses updated DSM-5 diagnoses and criteria, psychopharmacology, the psychiatric exam, and systems-level approaches to care. It also considers the relationships of the geriatric patient to family, community, and health care providers as they contribute to successful treatment. This handbook examines the biological changes associated with aging and addresses common mental health disorders of older adults. It presents clear clinical guidelines and demonstrates the use of relevant clinical tools and scales with illustrative examples. Additionally, the text delves into cultural differences that impact treatment and addresses the distinct needs of patients during a pandemic such as COVID-19. Key Features: Written specifically for APNs and students who work in the geropsychiatry field Presents evidence-based content within a holistic nursing framework Links psychopharmacological content with psychotherapy Describes cultural considerations in assessment and treatment during a pandemic such as COVID-19—in assessment and treatment Delivers key information on interprofessional approaches to patient care Includes Case studies with discussion questions Interprofessional Boxes contain key information on partnerships that can enhance care Evidence-Based Practice Boxes focus on proven strategies and resources Purchase includes digital access for use on most mobile devices or computers. |
| initial psychiatric evaluation template: Psychological Testing in the Service of Disability Determination Institute of Medicine, Board on the Health of Select Populations, Committee on Psychological Testing, Including Validity Testing, for Social Security Administration Disability Determinations, 2015-06-29 The United States Social Security Administration (SSA) administers two disability programs: Social Security Disability Insurance (SSDI), for disabled individuals, and their dependent family members, who have worked and contributed to the Social Security trust funds, and Supplemental Security Income (SSSI), which is a means-tested program based on income and financial assets for adults aged 65 years or older and disabled adults and children. Both programs require that claimants have a disability and meet specific medical criteria in order to qualify for benefits. SSA establishes the presence of a medically-determined impairment in individuals with mental disorders other than intellectual disability through the use of standard diagnostic criteria, which include symptoms and signs. These impairments are established largely on reports of signs and symptoms of impairment and functional limitation. Psychological Testing in the Service of Disability Determination considers the use of psychological tests in evaluating disability claims submitted to the SSA. This report critically reviews selected psychological tests, including symptom validity tests, that could contribute to SSA disability determinations. The report discusses the possible uses of such tests and their contribution to disability determinations. Psychological Testing in the Service of Disability Determination discusses testing norms, qualifications for administration of tests, administration of tests, and reporting results. The recommendations of this report will help SSA improve the consistency and accuracy of disability determination in certain cases. |
| initial psychiatric evaluation template: Clinician's Guide to Psychological Assessment and Testing John M. Spores, 2012-09-18 This nuts-and-bolts guide to conducting efficient and accurate psychological testing in clinical settings provides mental health professionals with experienced guidance in the entire process. It features a complete set of printed and electronic forms and templates for all aspects of assessment and testing, from the initial referral to the final report. It presents a standardized process of assessment, testing, interpretation, report-writing, and presenting feedback. Integral to the book is a review of psychological tests in seven key categories that most effectively address differential diagnostic dilemmas that clinicians are likely to encounter in practice. Numerous case examples illustrate the process in action. |
| initial psychiatric evaluation template: American Psychiatric Association Practice Guidelines American Psychiatric Association, 1996 The aim of the American Psychiatric Association Practice Guideline series is to improve patient care. Guidelines provide a comprehensive synthesis of all available information relevant to the clinical topic. Practice guidelines can be vehicles for educating psychiatrists, other medical and mental health professionals, and the general public about appropriate and inappropriate treatments. The series also will identify those areas in which critical information is lacking and in which research could be expected to improve clinical decisions. The Practice Guidelines are also designed to help those charged with overseeing the utilization and reimbursement of psychiatric services to develop more scientifically based and clinically sensitive criteria. |
| initial psychiatric evaluation template: The Non-Disclosing Patient Alexander Lerman, 2020-12-02 This volume is to examine the phenomena of non-disclosure in its wide ranging forms, study its properties, and to deepen the capacity of a mental health professional --as well as all clinicians who provide mental health counseling -- to detect and engage it across a range of clinical settings. Unengaged, sustained DNDD represents an impasse that is destructive to a clinician’s capacity to both understand and treat a patient. Successfully engaged, on the other hand, DNDD offers a unique perspective on in individuals anxieties, presuppositions, and mental functioning. A clinician who is both aware that a patient is withholding information, and comfortable with that awareness, may approach the patient material while listening for both indications of non-disclosed material and—critically—a growing awareness of psychopathology or other motivational forces driving non-disclosure. Written by experts in this area from both adult and child psychiatric specialties, this book is the first to address the issue of DNDD and present clinical pearls for addressing it. This text is a valuable resource for psychiatrists, psychologists, addiction medicine specialists, family physicians, and a wide array of clinicians treating patients who may struggle with disclosure and integrity. |
| initial psychiatric evaluation template: The Psychiatric Interview Allan Tasman, Jerald Kay, Robert Ursano, 2013-07-29 While the ABPN has now supplied such standards for psychiatry, psychiatric interviewing instruction has not been standardized in the US or in other countries. Similarly, the few psychiatric interviewing books available are written in textbook form, often long and often from the subpecialty perspective (e.g. psychodynamic interviewing). Critically, no interviewing guides to date take a true biopsychosocial perspective. That is, they limit themselves to “interviewing” as an isolated technique divorced from full patient assessment, which for quality patient care must include the interface of psychological and social components with biological components. Similarly, few interviewing texts are fully integrated with DSM/ICD categorical diagnostic schemata, even though these descriptive diagnostic systems represent the very core of our clinical language—the lingua franca of the mental health professions. Without good descriptive diagnoses there cannot be adequate communication of clinical data among providers. The proposed book will meet this need for training in biopsychosocial assessment and diagnosis. The patient interview is at the heart of psychiatric practice. Listening and interviewing skills are the primary tools the psychiatrist uses to obtain the information needed to make an accurate diagnosis and then to plan appropriate treatment. The American Board of Psychiatry and Neurology and the Accrediting Council on Graduate Medical Education identify interviewing skills as a core competency for psychiatric residents. The Psychiatric Interview: evaluation and diagnosis is a new and modern approach to this topic that fulfills the need for training in biopsychosocial assessment and diagnosis. It makes use of both classical and new knowledge of psychiatric diagnosis, assessment, treatment planning and doctor-patient collaboration. Written by world leaders in education, the book is based on the acclaimed Psychiatry Third Edition by Tasman, Kay et al, with new chapters to address assessment in special populations and formulation. The psychiatric interview is conceptualized as integrating the patient's experience with psychological, biological, and environmental components of the illness. This is an excellent new text for psychiatry residents at all stages of their training. It is also useful for medical students interested in psychiatry and for practicing psychiatrists who may wish to refresh their interviewing skills. |
| initial psychiatric evaluation template: The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder American Psychiatric Association, 2018-01-11 Alcohol use disorder (AUD) is a major public health problem in the United States. The estimated 12-month and lifetime prevalence values for AUD are 13.9% and 29.1%, respectively, with approximately half of individuals with lifetime AUD having a severe disorder. AUD and its sequelae also account for significant excess mortality and cost the United States more than $200 billion annually. Despite its high prevalence and numerous negative consequences, AUD remains undertreated. In fact, fewer than 1 in 10 individuals in the United States with a 12-month diagnosis of AUD receive any treatment. Nevertheless, effective and evidence-based interventions are available, and treatment is associated with reductions in the risk of relapse and AUD-associated mortality. The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder seeks to reduce these substantial psychosocial and public health consequences of AUD for millions of affected individuals. The guideline focuses specifically on evidence-based pharmacological treatments for AUD in outpatient settings and includes additional information on assessment and treatment planning, which are an integral part of using pharmacotherapy to treat AUD. In addition to reviewing the available evidence on the use of AUD pharmacotherapy, the guideline offers clear, concise, and actionable recommendation statements, each of which is given a rating that reflects the level of confidence that potential benefits of an intervention outweigh potential harms. The guideline provides guidance on implementing these recommendations into clinical practice, with the goal of improving quality of care and treatment outcomes of AUD. |
| initial psychiatric evaluation template: Essentials of Psychiatric Assessment Mohamed Ahmed Abd El-Hay, 2018-05-30 A psychiatric assessment is a structured clinical conversation, complemented by observation and mental state examination, and supplemented by a physical examination and the interview of family members when appropriate. After the initial interview, the clinician should be able to establish whether the individual has a mental health problem or not, the nature of the problem, and a plan for the most suitable treatment. Essentials of Psychiatric Assessment provides the resident or beginning psychiatrist with a complete road map to a thorough clinical evaluation. |
| initial psychiatric evaluation template: Clinical Guide to Psychiatric Assessment of Infants and Young Children Karen A. Frankel, Joyce Harrison, Wanjiku F.M. Njoroge, 2019-04-02 This book provides a clinical guide to the psychiatric assessment of infants and young children, birth through five years, and their families. It offers a comprehensive, data-rich framework for conducting mental health assessments of infants, toddlers, and preschoolers. The book includes a step-by-step guide for evaluation and assessment, reviewing relevant literature and best practices for working with very young children. It begins with an overview of the purpose and principles of psychiatric assessment and offers a protocol for planning and executing a thorough evaluation. Chapters examine critical aspects of the assessment process, including children’s relationships with parents/caregivers, assessment of parents, cultural considerations, and play behaviors. Chapters also provide illustrative case vignettes and information on specialized tools that can be adapted for use in a private office or training clinic. Topics featured in this book include: Play-based assessment models for accessing the inner world of young children. The effect of caregivers and their reflective functioning on the mental health of young children. The use of adult-report rating scales in the clinical assessment of young children. Psychopharmacologic considerations in early childhood. The Clinical Guide to Psychiatric Assessment of Infants and Young Children is a must-have resource for researchers, clinicians, and related professionals, and graduate students in infancy and early childhood development, pediatrics, social work, psychiatry, and public health. “The volume is both highly practical and up to date, impressively bridging the gap between science and practice. The book is an invaluable guide for students and trainees and an important reference for seasoned clinicians.” David Oppenheim, Ph.D., University of Haifa “The book integrates relational, developmental and social-emotional health dimensions within each chapter, reviewing subjective and objective measures in a range of domains. The book is clear and user-friendly. I wholeheartedly recommend it!” Daniel S. Schechter, M.D., New York University School of Medicine “This important new volume provides multiple perspectives on the entire range of assessment methods and procedures used in early childhood mental health. This is a vital read for students and practitioners.” Charles H. Zeanah, M.D., Tulane University |
| initial psychiatric evaluation template: Essentials of Psychiatric Diagnosis, Revised Edition Allen Frances, 2013-08-16 Grounded in author Allen Frances's extensive clinical experience, this comprehensive yet concise guide helps the busy clinician find the right psychiatric diagnosis and avoid the many pitfalls that lead to errors. Covering every disorder routinely encountered in clinical practice, Frances provides the ICD-9-CM and ICD-10-CM (where feasible) codes required for billing, a useful screening question, a colorful descriptive prototype, lucid diagnostic tips, and a discussion of other disorders that must be ruled out. The book closes with an index of the most common presenting symptoms, listing possible diagnoses that must be considered for each. Frances was instrumental in the development of past editions of the DSM and provides helpful cautions on questionable aspects of DSM-5. The revised edition features ICD-10-CM codes where feasible throughout the chapters, plus a Crosswalk to ICD-10-CM Codes in the Appendix. The Appendix, links to further coding resources, and periodic updates can also be accessed online (www.guilford.com/frances_updates). |
| initial psychiatric evaluation template: Oversight of the U.S. Department of Justice United States. Congress. Senate. Committee on the Judiciary, 2012 |
| initial psychiatric evaluation template: Clinical Interviewing, with Video Resource Center John Sommers-Flanagan, Rita Sommers-Flanagan, 2015-06-29 Clinical Interviewing, Fifth Edition blends a personal and easy-to-read style with a unique emphasis on both the scientific basis and interpersonal aspects of mental health interviewing. It guides clinicians through elementary listening and counseling skills onward to more advanced, complex clinical assessment processes, such as intake interviewing, mental status examination, and suicide assessment. Fully revised, the fifth edition shines a brighter spotlight on the development of a multicultural orientation, the three principles of multicultural competency, collaborative goal-setting, the nature and process of working in crisis situations, and other key topics that will prepare you to enter your field with confidence, competence, and sensitivity. |
| initial psychiatric evaluation template: Trauma-Informed Assessment with Children and Adolescents: Strategies to Support Clinicians Cassandra Kisiel, Tracy Fehrenbach, Lisa Conradi, Lindsey Weil, Ma MS, 2020-12-22 This book serves as a practical guide for clinicians and other professionals working with children and adolescents exposed to trauma, offering an overview and rationale for a comprehensive approach to trauma-informed assessment, including key domains and techniques. Building on more than 2 decades of work in collaboration with the National Child Traumatic Stress Network (NCTSN), the book provides strategies for conducting an effective trauma-informed assessment that can be used in practice to support the treatment planning and intervention process, family engagement and education, and collaboration and advocacy with other providers. As part of APA's Division 56 series, Concise Guides on Trauma Care, the book surveys a range of recommended tools and considerations for selecting and implementing those tools across stages of development and in relation to a child's sociocultural context. The authors also examine challenges that may arise in the context of trauma-informed assessment and suggest approaches to overcome those barriers. |
| initial psychiatric evaluation template: Practice Guideline for the Treatment of Patients with Schizophrenia American Psychiatric Association, 1997 The American Psychiatric Association (APA) is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. |
| initial psychiatric evaluation template: Bipolar Disorder Stephen M. Strakowski, Caleb M. Adler, David E. Fleck, Melissa P. DelBello, 2020 This book was written specifically with new psychiatrists and mental health practitioners in mind to facilitate their ability to understand and care for patients with bipolar disorder. |
| initial psychiatric evaluation template: Dsm-5 Made Easy James Morrison, 2017-01-01 |
| initial psychiatric evaluation template: Mental Health and Psychiatric Nursing Janet L. Davies, Ellen Hastings Janosik, 1991 |
| initial psychiatric evaluation template: Cultural Formulation Juan E. Mezzich, Giovanni Caracci, 2008 The publication of the Cultural Formulation Outline in the DSM-IV represented a significant event in the history of standard diagnostic systems. It was the first systematic attempt at placing cultural and contextual factors as an integral component of the diagnostic process. The year was 1994 and its coming was ripe since the multicultural explosion due to migration, refugees, and globalization on the ethnic composition of the U.S. population made it compelling to strive for culturally attuned psychiatric care. Understanding the limitations of a dry symptomatological approach in helping clinicians grasp the intricacies of the experience, presentation, and course of mental illness, the NIMH Group on Culture and Diagnosis proposed to appraise, in close collaboration with the patient, the cultural framework of the patient's identity, illness experience, contextual factors, and clinician-patient relationship, and to narrate this along the lines of five major domains. By articulating the patient's experience and the standard symptomatological description of a case, the clinician may be better able to arrive at a more useful understanding of the case for clinical care purposes. Furthermore, attending to the context of the illness and the person of the patient may additionally enhance understanding of the case and enrich the database from which effective treatment can be planned. This reader is a rich collection of chapters relevant to the DSM-IV Cultural Formulation that covers the Cultural Formulation's historical and conceptual background, development, and characteristics. In addition, the reader discusses the prospects of the Cultural Formulation and provides clinical case illustrations of its utility in diagnosis and treatment of mental disorders. Book jacket. |
| initial psychiatric evaluation template: Core Competencies for Psychiatric Practice Stephen C. Scheiber, Thomas A. Kramer, ABPN, 2008-08-13 The practice of medicine has changed radically during the past few decades. Patients -- better informed than ever -- now demand more of their physicians, viewing them as partners rather than revering them as sole decision-makers. In this environment, nonnegotiable core competencies -- ever-evolving and measured by certification, recertification, and, more recently, maintenance of certification -- are more important than ever. Written from the perspective of those responsible for educating and certifying the next generations of psychiatrists, this groundbreaking compendium by distinguished contributors offers -- for the first time -- a concise look at the final product of the June 2001 Invitational Core Competencies Conference sponsored by the American Board of Psychiatry and Neurology (ABPN) as regards psychiatry (with a future comparable publication focusing on neurology). Divided into four parts, Part I sets the stage for the current concept of physician competence by presenting a brief history of medical competence, explaining the logic behind the development of the current competence outline. Part II provides two different views of how to look at core competencies: how competence is defined by the Royal College of Physicians and Surgeons of Canada and, based on some of their work, what is currently being done in the United States. Part III discusses the organizing principles -- identified in 1999 by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) -- that frame all of our conversations about competence, as currently delineated for psychiatrists across the six core competency categories: Patient Care, Medical Knowledge, Interpersonal and Communications Skills, Practice-Based Learning and Improvement, Professionalism, and Systems-Based Practice. Also presented are discussions of when in a physician's career these competencies should be assessed and what methodologies would be appropriate for that assessment. Part IV discusses how the psychiatry core competencies are changing board certification and recertification. Also presented are informed predictions about the changes that medical school faculty and residency training directors will have to make and how practitioners will have to change behaviors to maintain their board certification. Concluding with an appendix outlining the six core competencies for psychiatry, this invaluable resource will both help psychiatric residents and their faculty and training directors understand the core competencies important to the ABPN and provide practitioners with a view of what will be contained in their upcoming maintenance of certification programs now being designed. |
| initial psychiatric evaluation template: Tools for Strengths-Based Assessment and Evaluation Catherine A. Simmons, Peter Lehmann, 2012-11-08 Print+CourseSmart |
| initial psychiatric evaluation template: Pharmacological Treatment of College Students with Psychological Problems Leighton Whitaker, Stewart Cooper, 2014-07-10 Get valuable insights into best practices and procedures for treatment Mental health practitioners across the country are increasingly treating students by combining the use of psychotropic medication with psychotherapy. Pharmacological Treatment of College Students with Psychological Problems explores in detail this uncritically accepted exponential expansion of the practice. Leading psychiatrists, psychologists, and social workers discuss the crucial questions and problems encountered in this widespread practice, and also present specific and differing models of combined therapy. This book critically examines several of the key issues, practices, and competing perspectives. Professionals working in college mental health are provided with valuable insights into best practices and procedures in split and integrated treatment. Various clinicians beyond the psychiatric field are prescribing psychotropic medications with increasing frequency. Pharmacological Treatment of College Students with Psychological Problems presents a wide range of viewpoints on this issue, offering evidence, arguments, and recommendations to clearly illustrate the need for increased attention to the use of psychotropic medications and show how psychotherapy may be safer and more beneficial. Chapters include discussions on withdrawing from medication successfully, long term perturbation effects, and differing models of combined therapy in practice. This resource is comprehensively referenced. Topics in Pharmacological Treatment of College Students with Psychological Problems include: identification of the key issues and practices of combining psychotropic medication with counseling in treatment elements of two separate university counseling centers and how they provide combined treatment emerging research on perturbation effects of use of psychotropic medications best practices in the combined treatment in college settings key unresolved questions that need further research bringing a more sophisticated level in the practice of combined treatment with college students Pharmacological Treatment of College Students with Psychological Problems is a valuable resource for all professionals from seasoned professionals to beginning practicum students. |
| initial psychiatric evaluation template: Assessment of Neuropsychological Functions in Psychiatric Disorders Avraham Calev, 1999 Assessment of Neuropsychological Functions in Psychiatric Disorders covers findings on all major psychiatric disorders. This book looks at neuropsychological assessment, phenomenology, and rehabilitation of psychiatric patients. |
| initial psychiatric evaluation template: SCID-5-CV Michael B. First, Janet B. W. Williams, Rhonda S. Karg, Robert L. Spitzer, 2015-11-05 The Structured Clinical Interview for DSM-5 --Clinician Version (SCID-5-CV) guides the clinician step-by-step through the DSM-5 diagnostic process. Interview questions are provided conveniently along each corresponding DSM-5 criterion, which aids in rating each as either present or absent. A unique and valuable tool, the SCID-5-CV covers the DSM-5 diagnoses most commonly seen in clinical settings: depressive and bipolar disorders; schizophrenia spectrum and other psychotic disorders; substance use disorders; anxiety disorders (panic disorder, agoraphobia, social anxiety disorder, generalized anxiety disorder); obsessive-compulsive disorder; posttraumatic stress disorder; attention-deficit/hyperactivity disorder; and adjustment disorder. It also screens for 17 additional DSM-5 disorders. Versatile in function, the SCID-5-CV can be used in a variety of ways. For example, it can ensure that all of the major DSM-5 diagnoses are systematically evaluated in adults; characterize a study population in terms of current psychiatric diagnoses; and improve interviewing skills of students in the mental health professions, including psychiatry, psychology, psychiatric social work, and psychiatric nursing. Enhancing the reliability and validity of DSM-5 diagnostic assessments, the SCID-5-CV will serve as an indispensible interview guide. |
| initial psychiatric evaluation template: Assessing Mental Health and Psychosocial Needs and Resources World Health Organization, 2013 Mental health and psychosocial support (MHPSS) is a term used to describe a wide range of actions that address social, psychological and psychiatric problems that are either pre-existing or emergency-induced. These actions are carried out in highly different contexts by organizations and people with different professional backgrounds, in different sectors and with different types of resources. All these different actors--and their donors--need practical assessments leading to recommendations that can be used immediately to improve people's mental health and well-being. Although a range of assessment tools exist, what has been missing is an overall approach that clarifies when to use which tool for what purpose. This document offers an approach to assessment that should help you review information that is already available and only collect new data that will be of practical use, depending on your capacity and the phase of the humanitarian crisis. This document is rooted in two policy documents, the IASC Reference Group s (2010) Mental Health and Psychosocial Support in Humanitarian Emergencies: What Should Humanitarian Health Actors Know? and the Sphere Handbook's Standard on Mental Health (Sphere Project, 2011). It is written primarily for public health actors. As the social determinants of mental health and psychosocial problems occur across sectors, half of the tools in the accompanying toolkit cover MHPSS assessment issues relevant to other sectors as well as the health sector. |
| initial psychiatric evaluation template: Psychiatry in Primary Care David S Goldbloom, Jon Davine, 2011-03 Psychiatry in Primary Care: A Concise Canadian Pocket Guide is a comprehensive, practical resource designed to support the work of primary care providers who encounter challenging mental health problems in their daily practices. Following a just the pearls approach, Psychiatry in Primary Care provides realistic, clinically-tested guidance on detecting and managing mental health problems within the primary care context. Topics covered range from depression, anxiety and personality disorders to psychotherapy in primary care and managing mental health-related disability and insurance claims. Designed for quick access, the guide features useful tools, established diagnostic criteria, useful approaches and alternatives to pharmacotherapies and other resources. Edited by David Goldbloom and Jon Davine, Psychiatry in Primary Care features leading contributors from across Canada. |
| initial psychiatric evaluation template: Massachusetts General Hospital Handbook of General Hospital Psychiatry E-Book Theodore A. Stern, Oliver Freudenreich, Felicia A. Smith, Gregory L. Fricchione, Jerrold F. Rosenbaum, 2017-08-09 For generations of practitioners, the Massachusetts General Hospital Handbook of General Hospital Psychiatry has been and is the gold standard guide to consultation-liaison psychiatry and psychosomatic medicine. The fully updated 7th Edition, by Drs. Theodore A. Stern, Oliver Freudenreich, Felicia A. Smith, Gregory L. Fricchione, and Jerrold F. Rosenbaum, provides an authoritative, easy-to-understand review of the diagnosis, evaluation, and treatment of psychiatric problems experienced by adults and children with medical and surgical conditions. Covers the psychological impact of chronic medical problems and life-threatening diseases, somatic symptom disorders, organ donors and recipients, pain, substance abuse, and polypharmacy, including a thorough review of drug actions and interactions, metabolism, and elimination. - Features DSM-5 updates throughout, as well as case studies in every chapter. - Contains practical tips on how to implement the most current and effective pharmacological therapies as well as cognitive-behavioral approaches. - Expert Consult eBook version included with purchase. This enhanced eBook experience allows you to search all of the text, figures, images, videos (including video updates), glossary, and references from the book on a variety of devices. |
| initial psychiatric evaluation template: Case Conceptualization Len Sperry, Jon Sperry, 2020-05-27 Integrating recent research and developments in the field, this revised second edition introduces an easy-to-master strategy for developing and writing culturally sensitive case conceptualizations and treatment plans. Concrete guidelines and updated case material are provided for developing conceptualizations for the five most common therapy models: Cognitive-Behavioral Therapy (CBT), Psychodynamic, Biopsychosocial, Adlerian, and Acceptance and Commitment Therapy. The chapters also include specific exercises and activities for mastering case conceptualization and related competencies and skills. Also new to this edition is a chapter on couple and family case conceptualizations, and an emphasis throughout on trauma. Practitioners, as well as graduate students in counseling and in clinical psychology, will gain the essential skills and knowledge they need to master case conceptualizations. |
| initial psychiatric evaluation template: Measuring Health and Disability World Health Organization, 2010 The World Health Organisation had just published a generic assessment instrument to measure general health and disability levels: the WHO Disability Assessment Schedule, WHODAS 2.0. WHODAS 2.0 is based on the International Classification of Functioning, Disability and Health (ICF). It was developed and tested internationally and is applicable in different cultures both in general populations and in clinical settings. It can be used as a general measure across all diseases. This manual is aimed at public health professionals, doctor, other health professionals (for example rehabilitation professionals, physical therapists and occupational therapists), health policy planners, social scientists and others involved in studies on disability and health. -- Publisher. |
| initial psychiatric evaluation template: Psychotherapy for the Advanced Practice Psychiatric Nurse, Second Edition Kathleen Wheeler, 2013-12-11 Print+CourseSmart |
| initial psychiatric evaluation template: Psychiatry in Practice Andrea Fiorillo, Umberto Volpe, Dinesh Bhugra, 2016 Provides detailed tips and advice to ensure early career psychiatrists and those that wish to enhance their practical psychiatry skills are prepared for all scenarios. |
| initial psychiatric evaluation template: Functional Assessment for Adults with Disabilities National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Health Care Services, Committee on Functional Assessment for Adults with Disabilities, 2019-08-31 The U.S. Social Security Administration (SSA) provides disability benefits through the Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) programs. To receive SSDI or SSI disability benefits, an individual must meet the statutory definition of disability, which is the inability to engage in any substantial gainful activity [SGA] by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. SSA uses a five-step sequential process to determine whether an adult applicant meets this definition. Functional Assessment for Adults with Disabilities examines ways to collect information about an individual's physical and mental (cognitive and noncognitive) functional abilities relevant to work requirements. This report discusses the types of information that support findings of limitations in functional abilities relevant to work requirements, and provides findings and conclusions regarding the collection of information and assessment of functional abilities relevant to work requirements. |
| initial psychiatric evaluation template: Psychiatric Case Studies for Advanced Practice Kathleen Prendergast, 2018-04-05 Get much-needed exposure to real-world clinical scenarios and psychiatric evaluations, with this invaluable guide to positive, effective psychiatric advance practice nursing care. For an expert guide to providing patient-centered, evidence-based psychiatric care, keep Psychiatric Case Studies for Advanced Practice by your side. Practical and easy-to-follow, these more than 50 case scenarios clearly display the complaints, diagnoses, and treatments of the most common psychiatric disorders, supporting the critical decision-making skills of nurses practicing in a broad range of settings. Psychiatric, family, emergency, and general practice nurse practitioners of all experience levels will find this an invaluable aid for creating an informed, holistic practice. Follow the real-life cases and expert analysis of psychiatric patients of a wide variety of ages, backgrounds, and conditions . . . Real-world child, adolescent, adult, and geriatric inpatient and outpatient psychiatric case studies that emphasize problem-based learning and an evidence-based practice Current diagnostic content from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), that includes DSM-5’s newer diagnoses—gender dysphoria, binge eating disorder, and autism spectrum, plus current treatments for alcohol and opiate addiction Sample routine screening tools that offer convenient checklists and handouts to support patient treatment Content presented in a simple format—organized by age and indexed by diagnostic category for quick reference Each case presented in a standard format: chief complaint, history, mental status, diagnosis, differential diagnosis, treatment plan, and rationale for treatment prescribed—with questions at the end that guide you to create a diagnosis using the DSM-5 Cases addressing a wide range of disorders and supporting all experience levels in a variety of treatment settings—counseling centers, correctional facilities, homeless shelters, inpatient psychiatric units, and hospital consultation and liaison services Treatments and rationales that represent current, evidence-based research—treatment sections divided into psychopharmacology, diagnostic tests, referral, psychotherapy, and psychoeducatio Supplemental teaching tool for graduate psychiatric nurse practitioner/APN programs |
| initial psychiatric evaluation template: The Child Clinician's Report-Writing Handbook Ellen Braaten, 2019-09-18 Now revised and updated, this indispensable tool streamlines the process of conducting child and adolescent assessments and producing high-quality reports. In a convenient large-size format, the book is filled with interview questions and reproducible forms for collecting pertinent information from children, parents, and teachers; wording to describe more than 100 commonly used tests; and menus of terms and phrases for each section of a report. Formats and writing tips are provided for diagnostic, personality, and neuropsychological reports; treatment plans; progress notes; and more. Other user-friendly features include lists of medications and abbreviations and recommended print and online resources for professionals and parents. Purchasers get access to a Web page where they can download and print the reproducible materials. New to This Edition *Revised throughout for DSM-5 and ICD-10-CM. *Includes the most current test batteries and rating scales. *Updated resources for professionals and parents. *Reproducible materials now available online. |
| initial psychiatric evaluation template: Psychiatry, 2 Volume Set Allan Tasman, Jerald Kay, Jeffrey A. Lieberman, Michael B. First, Michelle Riba, 2015-03-30 Now in a new Fourth Edition, Psychiatry remains the leading reference on all aspects of the current practice and latest developments in psychiatry. From an international team of recognised expert editors and contributors, Psychiatry provides a truly comprehensive overview of the entire field of psychiatry in 132 chapters across two volumes. It includes two new sections, on psychosomatic medicine and collaborative care, and on emergency psychiatry, and compares Diagnostic and Statistical Manual (DSM-5) and International Classification of Diseases (ICD10) classifications for every psychiatric disorder. Psychiatry, Fourth Edition is an essential reference for psychiatrists in clinical practice and clinical research, residents in training, and for all those involved in the treatment psychiatric disorders. Includes a a companion website at www.tasmanpsychiatry.com featuring PDFs of each chapter and downloadable images |
| initial psychiatric evaluation template: The Mental Status Examination in Neurology Richard L. Strub, F. William Black, 2000 Simplified explanation of exam procedures such as assessment of level of consciousness, language acuity, memory, and attention Pocket card summarizes the main points to remember in assessing mental status in limited patient-contact time DSM-IV diagnostic criteria are covered to ease filling out insurance forms Findings about cognition and testing a patient's mental function Covers the refinement of testing procedures and the psychological test battery to speed up the exam Presents age-related norms, important when assessing the elderly for early dementia Reviews ways to use the exam as a screening procedure, particularly when diagnosing dementia and differentiating between organic and functional disorders |
| initial psychiatric evaluation template: Psychiatric Care of the Medical Patient Barry S. Fogel, Donna B. Greenberg, 2015-05-28 The third edition of Psychiatric Care of the Medical Patient brings a classic reference text into the twenty-first century. It combines critical scholarship with the voice of expert clinicians who work at the interface of psychiatry with medical specialties. It is meant to be read for pleasure as well as consulted as a reference. The editors have worked with the authors to bring a consistent perspective to the book - one that sees the medical psychiatrist as an agent for bringing a more comprehensive perspective to medical care. Even seasoned and knowledgeable practitioners will find much that is new to them in this book. The volume covers topics in depth that other books in the field may not cover at all, such as the use of herbal and nutritional therapies for medical-psychiatric symptoms and syndromes, and the choice of questionnaires to supplement history-taking. It looks at old topics in a new way: The chapter on the physical examination applies psychometric considerations to the Babinski sign, describes the method and application of quantitative bedside olfactory testing, and discusses smartphone apps to improve the sensitivity of the examination. Psychiatric Care of the Medical Patient, 3rd Edition provides concepts and information to facilitate the dialogue between psychiatrists and general medical specialists - minimizing psychiatric jargon and speaking in the common language of caring and curious physicians. |
| initial psychiatric evaluation template: Mental Health for Emergency Departments , 2009 |
The American Psychiatric Association Practice Guidelines for …
uation, APA recommends (1C) that the initial psychiatric evaluation of a patient include: † Psychiatric review of systems (I), including anxiety symptoms and panic attacks (III) † …
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1. What are the primary aims of the first psychiatric interview? To make an initial differential diagnosis and to formulate a treatment plan. These goals are achieved by: • Arriving at an …
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The American Psychiatric Association Practice Guidelines for …
APA recommends (1C) that the initial psychiatric evaluation of a patient include assessment of the following: † Past and current psychiatric diagnoses (I, III) † Prior psychotic or aggressive …
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