1. Initial PsychiatricInitial Psychiatric
AssessmentsAssessments
Teresa Chahine MSN, PMHNPTeresa Chahine MSN, PMHNP
Oakland University, School of NursingOakland University, School of Nursing

2. Components ofComponents of
Mental Health HistoryMental Health History
 Patient IdentificationPatient Identification
 Chief ComplaintChief Complaint
 Associated Symptoms Affecting FunctioningAssociated Symptoms Affecting Functioning
 History of Presenting IllnessHistory of Presenting Illness
 Past Psychiatric HistoryPast Psychiatric History
 Substance Use HistorySubstance Use History
 Medical-Surgical HistoryMedical-Surgical History
 Social HistorySocial History
 Mental Status ExaminationMental Status Examination
 Safety AlertsSafety Alerts

3. Patient IdentificationPatient Identification
 NameName
 AgeAge
 GenderGender
 RaceRace
 AddressAddress
 Emergency ContactEmergency Contact
 Guardianship StatusGuardianship Status
 Legal HistoryLegal History
 Evaluation StatusEvaluation Status
 VoluntaryVoluntary
 PetitionedPetitioned
 Court OrderCourt Order
 Modified Court OrderModified Court Order
 Insurance CoverageInsurance Coverage
 Living SituationLiving Situation
 Source of IncomeSource of Income
 AllergiesAllergies

4. Chief ComplaintChief Complaint
 What does the client see as the presenting problem.What does the client see as the presenting problem.
 Critical Characteristics:Critical Characteristics:
 OnsetOnset
 PrecipitantsPrecipitants
 Aggravating factors/StressorsAggravating factors/Stressors
 DurationDuration
 SeveritySeverity
 Associated symptomsAssociated symptoms
 What relieves symptoms/coping strategiesWhat relieves symptoms/coping strategies
 Patient’s understanding of problemPatient’s understanding of problem

5. Associated SymptomsAssociated Symptoms
 Self Harm*Self Harm*
 Aggression/AgitationAggression/Agitation
 Violence towards othersViolence towards others
 Impulsivity*Impulsivity*
 Hopelessness*Hopelessness*
 HelplessnessHelplessness
 Activities of Daily LivingActivities of Daily Living
 Social CircumstancesSocial Circumstances
 Work PerformanceWork Performance
 Anxiety*Anxiety*
 Panic Attacks*Panic Attacks*
 AnhedoniaAnhedonia
 PsychosisPsychosis
 Emotional StateEmotional State
 Coping StrategiesCoping Strategies
 AppetiteAppetite
 Sleep DisturbanceSleep Disturbance
 Global Insomnia*Global Insomnia*
* These symptoms are directly correlated to suicide risk factors.

6. Level of FunctioningLevel of Functioning
Activities of Daily LivingActivities of Daily Living
 Ability to bathe, etcAbility to bathe, etc
 Adhere to treatmentAdhere to treatment
 Attend to houseworkAttend to housework
 Maintain EmploymentMaintain Employment
 HobbiesHobbies
 SocializationSocialization
AppearanceAppearance
 Physical CharacteristicsPhysical Characteristics
 DressDress
 GroomingGrooming
 HygieneHygiene
 Eye ContactEye Contact
 Facial ExpressionFacial Expression

7. History of Presenting IllnessHistory of Presenting Illness
Past Psychiatric HxPast Psychiatric Hx
 Current TreatmentCurrent Treatment
 Current MedicationsCurrent Medications
 Onset of illnessOnset of illness
 HospitalizationsHospitalizations
 History of AdherenceHistory of Adherence
 History of Trauma:History of Trauma:
 Child AbuseChild Abuse
 RapeRape
 Domestic ViolenceDomestic Violence
 Family Psychiatric HistoryFamily Psychiatric History
Past Addiction HxPast Addiction Hx
 Current UseCurrent Use
 Current TreatmentCurrent Treatment
 History of WithdrawalsHistory of Withdrawals
 DTsDTs
 SeizuresSeizures
 Onset of UseOnset of Use
 Periods of SobrietyPeriods of Sobriety
 History of TreatmentHistory of Treatment
 Family Addiction HistoryFamily Addiction History

8. Medical-Surgical HistoryMedical-Surgical History
 Serious or Chronic IllnessesSerious or Chronic Illnesses
 Current MedicationsCurrent Medications
 Recent HospitalizationsRecent Hospitalizations
 SurgeriesSurgeries
 InjuriesInjuries
 AllergiesAllergies

9. Social HistorySocial History
 Living SituationLiving Situation
 RelationshipsRelationships
 Marital StatusMarital Status
 Current RelationshipCurrent Relationship
 Longest RelationshipLongest Relationship
 Family StructureFamily Structure
 Support SystemSupport System
 EducationalEducational
 Occupation/Work HistoryOccupation/Work History
 Financial SupportFinancial Support
 Ethnic or Spiritual Issues (if apply)Ethnic or Spiritual Issues (if apply)

10. Mental Status ExamMental Status Exam
 LethalityLethality
 Self HarmSelf Harm
 Assaultive BehaviorAssaultive Behavior
 Destruction to PropertyDestruction to Property
 Mood & AffectMood & Affect
 Speech PatternSpeech Pattern
 Thought PatternThought Pattern
 OrientationOrientation
 Thought ContentThought Content
 MemoryMemory
 HallucinationsHallucinations
 DelusionsDelusions
 InsightInsight
 JudgmentJudgment
Please give specific examples and quote client’s statements.

11. Safety AlertsSafety Alerts
 Medical conditions requiringMedical conditions requiring immediateimmediate
treatment.treatment.
 Active alcohol or benzodiazapine intoxicationActive alcohol or benzodiazapine intoxication
or withdrawal.or withdrawal.
 Actively psychotic with commandActively psychotic with command
hallucinations.hallucinations.
 Actively suicidal or homicidal with intent.Actively suicidal or homicidal with intent.
 Dependent children suspected of beingDependent children suspected of being
neglected or abused by client.neglected or abused by client.

12. Special Considerations:Special Considerations:
Pre-teen and TeensPre-teen and Teens
Ages 8-17Ages 8-17
 Suicidal AssessmentSuicidal Assessment
 Substance Abuse/DependenceSubstance Abuse/Dependence
 Attention-Deficit and DisruptiveAttention-Deficit and Disruptive
Behavior DisordersBehavior Disorders
 Tic DisordersTic Disorders
 Communication DisordersCommunication Disorders
 Learning/Developmental DisordersLearning/Developmental Disorders
 Elimination DisordersElimination Disorders

13. ImpressionImpression
 Summary of data which supports theSummary of data which supports the
documented diagnoses.documented diagnoses.
 Axis I through VAxis I through V
 Severity of illness and intensity of care.Severity of illness and intensity of care.
 Plan of carePlan of care
 Nursing interventions and outcomes.Nursing interventions and outcomes.
 Disposition (referrals)Disposition (referrals)

14. Multiaxial SystemMultiaxial System
 Axis IAxis I Clinical DisordersClinical Disorders
--Other conditions that may be aOther conditions that may be a
focus of clinical attention.focus of clinical attention.
 Axis IIAxis II Personality DisordersPersonality Disorders
Mental RetardationMental Retardation
 Axis IIIAxis III General Medical ConditionsGeneral Medical Conditions
 Axis IVAxis IV Psychosocial and EnvironmentalPsychosocial and Environmental
ProblemsProblems
 Axis VAxis V Global Assessment of FunctioningGlobal Assessment of Functioning

15. Axis IV: Psychosocial andAxis IV: Psychosocial and
Environmental ProblemsEnvironmental Problems
 Primary Support GroupPrimary Support Group
 Social EnvironmentSocial Environment
 EducationEducation
 OccupationalOccupational
 HousingHousing
 EconomicEconomic
 Access to Health CareAccess to Health Care
 Interaction with legal/criminal systemInteraction with legal/criminal system
 Other psychosocial/environmental problemsOther psychosocial/environmental problems

16. GGlobal Assessment of Functioninglobal Assessment of Functioning
(GAF)(GAF)
 100-91 life’s problems never seem to get out of hand
 90-81 good functioning in all areas, no more than
everyday issues
 80-71 transient and expectable reactions to psycho-
social stressors
 70-61 mild symptoms
 60-51 moderate symptoms
 50-41 Serious symptoms
 40-31 unable to work, major impairment in several
areas
 30-21 Behavior is considerably influenced by delusions
or hallucinations OR serious impairment in
communication or judgment
 20-11 danger of hurting self or others without clear
expectations of death.
 10-1 Persistent danger of severely hurting self or

17. EndEnd