Psych Eval on Post traumatic Stress Disorder
Initial Psychiatric Assessment Template
Name of Interviewer: (Your Name)
DATE:
Identifying Date:
Name, age, sex, language
Chief Complaint:
Reason why patient has come for help, in his/her own words using direct quotations
HPI:
Course & chronology of symptoms – onset, symptoms, changes at home or work, setting, problems w/family or friends. Include Duration, Severity, Contributing Factors, Signs & Symptoms.
Over the past 2 weeks regarding HPI:
SIGECAPS (This is a very useful tool for questioning regarding symptomatology in a logical, organized fashion): S=Sleep; I=Interest (anhendonia); G=Guilt; E=Energy; C=Concentration/Focus (increased or decreased); A=Anxiety; P=Psychosis/Psychomotor; S=Suicidal ideations, safety. Also ask about thoughts to harm others.
Sleep – problems falling or staying asleep, how many hrs/night, naps
Interest – in activities (anhedonia). What do you do for fun & when was the last time you did this?
Guilt – helpless, hopeless, (worthlessness), crying spells (worry)
Energy – increased or decreased
Concentration – assess later after treatment started
Appetite – increased or decreased, weight loss or gain
Psychomotor – observe for retardation or agitation
Suicidal ideation – SI/HI
Psychosis: any AH/VH
Mania: decreased need for sleep? Racing thoughts, pressured speech, flight of ideas, hypersexuality, overspending, gambling?
Anxiety: Describe how it feels in your body?
Safety: Do you feel safe in your environment?
Past Psych History:
Past episodes requiring psych care (inpatient, outpatient, presenting symptoms, extent of incapacity, type of treatment, any medications utilized in the past and response, names of doctors & hospitals involved
PMH:
PSH:
Allergies:
Current Medications: Including prescribed and OTC
Substance Abuse:
Currently or in the past – ETOH, nicotine, marijuana, Spice, huffing, opiates, amphetamines, meth, cocaine, BZO’s (CAGE = Cutting down, Annoyed, Guilty, Eye Opener). Including any past history of rehab/treatment programs.
Family Medical History:
Other family members with psychiatric/mental problems including Bipolar Disorder, Anxiety, Depression, Schizophrenia, Substance abuse, hospitalizations & any psych meds utilized
Family History of Mental Illness:
Social History:
Marital status, children, relationship w/patient, living situation, education, occupation, income, encounters with the law/legal problems. Get good background information including the following: Where were you born, who raised you, what was your childhood like, any past history of trauma (physical, emotional, sexual), highest level of education.
Legal: Any history of legal problems, arrests, etc.
HABITS: Ask about caffeine intake including coffee, sodas, energy drinks.
History of Trauma: Any history of Emotional, Physical or Sexual abuse as a child or adult
Perform a General ROS and then a Psychiatric ROS:
General:
HEENT:
Resp:
Cardio:
GI:
GU:
NEURO:
ENDOCRINE:
HEME:
SKIN:
Consciousness:
Reduced, clouded, narrowed, expanded
MENTAL STATUS EXAM
Orientation:
Time, place, situation, self
Attention, Memory:
Apperception, concentration – (100 – 7 = 93 – 7 = 85 – 7 = 78 – 7 = 71 – 7 = 64 …..), memorization (apple, table, cello), retention, confabulations, paramnesias; impaired memorization and ocular motor function; consider Wernicke’s encephalopathy!
Formal Thought Disorders:
Thinking – inhibited, retarded, circumstantial, restricted;
Formal order – preservation, rumination, pressured thinking, flight of ideas, tangential thinking, blocking, incoherence;
Perception and abstract thinking – explain proverbs, neologisms
Phobias & Compulsions:
Suspiciousness, hypochondriasis (non-delusional), phobias, obsessive thoughts, compulsive impulses, compulsive actions
Delusions:
Ask specific questions. Often in schizophrenia – delusional references, delusions of persecution; often in affective psychosis – delusions of guilt or of poverty; hypochondriacal delusions; often in manic – DO or schizophrenia – delusions of grandeur; further delusions – delusional ideas, systemic delusions, delusional dynamics, delusional jealousy, other delusions
Perception:
Illusions; hallucinations – verbal auditory, visual, bodily, olfactory
Loss of Ego Boundaries:
Derealization, depersonalization, thought broadcasting, withdrawal, thought insertion, other symptoms
Disturbances of Affect:
Depressive DO: perplexity, loss of feeling, blunted affect, depressed mood, hopelessness, anxiety, inadequacy, feelings of guilt, feelings of impoverishment
Manic DO: euphoria, dysphoria, irritability, exaggerated self-esteem
Schizophrenia: ambivalence, parathymia
Organic DO: affective lability/incontinence
Others: loss of vitality, restlessness, complaintive, affective rigidity
Psychomotor Disturbances:
Volition: lack of drive, inhibited, increased
motor activity: motor restlessness, parakinesia, mannerisms, histrionic
speech: mutism, logorrhea,
catatonic symptoms: negativism, stupor, waxy flexibility
Introspection, Judgement & Insight, Suicidal thoughts (ask specific questions)
INVENTORY OF PATIENT’S ASSETS/STRENGTHS: (Indicate those present)
General Fund of Knowledge Average or Above Average; Intelligence; Active Sense of Humor; Supportive Family / Friends
Physical Health; Motivation for Treatment/ Growth; Capable of Independent Living; Ability for Insight
Communication Skills; Financial Means; Religious Affiliation; Hobbies / Interests
Work/Volunteer Skills; Other: List Below
INVENTORY OF PATIENT’S LIABILITIES: (Indicate those present)
Unresponsive; Uncooperative; Lack of Support System; Unmotivated
Financial Difficulties; Legal Difficulties; Marital Difficulties; Lack of Coping Skills
Poor Judgment; Limited Insight; Limited Cognitive Abilities; Other: List Below
Diagnosis: (Include most likely diagnosis along with differential diagnoses as well as corresponding ICD-10 codes)
Treatment Plan: (Include thorough treatment plan including recommendations for medication management, therapy, labs/other diagnostic studies, medication side effects and health promotion/prevention strategies)Northwestern State University
Department of Graduate Studies and Research in Nursing
Grading Rubric for Psychiatric Evaluation and Treatment Plan
NURG 5910
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