Adult Psychiatric Diagnostic Evaluation

Patient identifiers: [Patient identifiers per local policy]

Age: [Age in years]

Date of service: [Date]

Location/setting: [Clinic / Hospital / Other setting]

Modality: [in-person / telehealth] (If telehealth, document patient location, clinician location, consent obtained, and any limitations of the exam.)

Clinician: [Clinician name, credentials]

Referral source: [Referral source or self-referred]

Sources of information: [Patient / collateral contacts (name, relationship) / medical records / PDMP reviewed (yes/no, date) / other] (List all sources used; specify if collateral or records are pending.)

Interpreter: [Interpreter used: Yes (language) / No] (If used, include interpreter details per local policy.)

Reliability/limitations: [Reliability of history and any limitations] (Note intoxication, cognitive impairment, language barriers, acute distress, or other factors affecting data quality. If no limitations, state "History considered reliable.")

Chief Concern

Patient statement: "[Patient's stated reason for visit in direct quote]" (Use a concise quote only if clinically meaningful.)

Clinician summary: [1–2 sentence summary of presenting problems and urgency] (Capture acuity, main symptoms, and immediate safety or medical concerns.)

History of Present Illness

[Narrative of symptom onset, duration, course, and precipitating factors with embedded timeline] (Integrate mood, anxiety, psychosis, sleep, appetite, energy, cognitive symptoms, and other relevant domains. Include pertinent positives and negatives. Describe functional impact on work, relationships, and daily activities. Document safety-related elements within the narrative: passive/active suicidal ideation, self-harm urges/behaviors, homicidal ideation, command hallucinations, agitation, intoxication/withdrawal concerns. Summarize prior and current treatments for this episode with response and adverse effects. If a domain was assessed and negative, state explicitly. If not assessed, note that and why if clinically relevant.)

Past Psychiatric History

• Prior diagnoses: [Record-based diagnoses] / [Patient-reported diagnoses] (Differentiate clearly.)
• Outpatient care: [Prior psychiatry visits, therapy modalities, frequency, dates if known]
• Hospitalizations/ED visits: [Number, dates if known, reasons, outcomes]
• Medication trials: [Medication, max dose, duration, response, adverse effects, reason stopped] (List most relevant; include current and past.)
• Psychotherapy: [Type, duration, response]
• Self-harm/suicide attempts: [Method, lethality, medical consequences, context, dates if known] (Keep factual and concise.)
• Violence/aggression: [History if clinically relevant, context, legal outcomes if any] (Omit if none.)
• Somatic treatments: [ECT / TMS / ketamine or other; dates, response, adverse effects] (Omit if none.)
• Trauma history: [Broad categories of exposure, approximate timing, current impact, PTSD symptoms if present] (Note if patient declined to discuss details. Omit if not assessed or not relevant.)

Substance Use History

(Document each substance with route, amount, frequency, duration, and last use. Include intoxication/withdrawal symptoms, consequences, and prior treatment. For opioid use, note overdose history and naloxone access. If no substance use, state "Denies current or past substance use." If not assessed, state explicitly.)

• [Substance]: [Route, amount, frequency, duration, last use; intoxication/withdrawal symptoms; consequences; prior treatment]
• [Substance]: [Route, amount, frequency, duration, last use; intoxication/withdrawal symptoms; consequences; prior treatment]

Medical History and Medications

• Medical conditions: [Active and relevant past conditions, including metabolic, cardiovascular, endocrine]
• Neurologic history: [Seizures, TBI, stroke, neurocognitive disorders] (Omit if none.)
• Sleep disorders/pain: [OSA, RLS, chronic pain, migraines] (Omit if none.)
• Primary care: [Name/clinic if known; last visit if known]
• Current medications: [Psychiatric medications with doses], [Non-psychiatric medications], [OTC], [Supplements] (Note adherence and side effects when relevant.)
• Allergies: [Medication/agent and reaction type, or NKDA]
• Medication list completeness: [Complete / Incomplete] (If incomplete, document efforts made and limitations.)

Family Psychiatric History

• [Relation: condition(s), treatment history if known, suicide attempts/completions]
• [Significant medical conditions with psychiatric relevance (e.g., thyroid, epilepsy)] (Omit if none.)

Social History

• Living situation: [Housing type, stability, with whom]
• Relationships/dependents: [Relationship status, dependents, caregiving roles]
• Education/employment: [Highest level, current occupation, disability/leave status]
• Psychosocial stressors: [Current major stressors]
• Legal history: [If clinically relevant] (Omit if none or not relevant.)
• Lethal means access: [Firearms/other means access and storage practices] (Include when indicated by risk concerns.)
• Supports: [Family, friends, community resources]

Mental Status Examination

• Appearance: [Grooming, dress, apparent age]
• Behavior/psychomotor: [Cooperative/guarded, agitation/retardation, abnormal movements]
• Speech: [Rate, volume, fluency]
• Mood (patient-stated): "[Mood]"
• Affect: [Range, intensity, stability, congruence]
• Thought process: [Linear / circumstantial / tangential / loose associations / other]
• Thought content: [Delusions, obsessions, preoccupations; SI/HI presence or absence noted briefly] (Detail SI/HI in risk assessment section.)
• Perceptions: [Hallucinations/illusions, or none]
• Cognition: [Orientation, attention, memory grossly; formal testing results if performed]
• Insight: [Good / fair / limited / poor]
• Judgment: [Good / fair / limited / poor]
• Impulse control: [Intact / fair / impaired]

Suicide Risk Assessment

Screening: [Validated tool used and result, if applicable] (e.g., PHQ-9 item 9, C-SSRS, ASQ; include score and interpretation.)

Suicide inquiry: [Current ideation: none / passive / active], [Frequency and intensity], [Plan: present/absent, details if present], [Intent: present/absent], [Preparatory behaviors], [Access to means, especially firearms]. (Reference prior attempts from Past Psychiatric History with salient risk details.)

Risk factors: [Dynamic: current symptoms, hopelessness, impulsivity, substance use, psychosis, agitation, recent losses, access to means] [Static: prior attempts, family history of suicide, chronic medical illness]

Protective factors: [Reasons for living, social supports, engagement in care, coping strategies, dependents, beliefs/values]

Risk level: [low / moderate / high] with brief justification. [Acute / chronic] risk distinguished when clinically relevant.

Mitigation plan: [Safety planning steps taken or discussed], [Means restriction counseling provided], [Crisis resources provided], [Disposition rationale], [Follow-up timing matched to risk level]

(If suicidal ideation is denied, explicitly document denial of ideation, plan, and intent—not just "denies SI.")

Violence Risk Assessment

[Current homicidal ideation: present/absent], [Identified targets], [Plan/intent], [Access to weapons], [History of violence], [Psychosis-related risk factors], [Overall risk level: low / moderate / high with brief justification], [Mitigation plan if indicated]. (If no indicators present, a brief statement such as "Patient denies homicidal ideation, no identified risk factors for violence" is sufficient.)

Physical Exam and Diagnostic Studies

• Vitals: [BP, HR, weight/BMI] (Include when initiating or managing medications with metabolic or cardiovascular implications.)
• Focused physical exam: [Pertinent findings only if performed] (Do not document systems not examined. State "Deferred" with reason if applicable.)
• Labs/imaging reviewed: [Relevant results and dates]
• Studies ordered today: [Test ordered: clinical rationale] (Do not list tests without documented indication.)

Diagnostic Formulation

Summary statement: [2–4 sentence summary: who the patient is, key symptoms and timeline, key risk factors, functional impairment]

Biopsychosocial formulation: [Predisposing factors (genetics, trauma, developmental)], [Precipitating factors (recent stressors, substance changes)], [Perpetuating factors (avoidance, sleep disruption, isolation, ongoing substance use)], [Protective factors]

Differential diagnosis:

• [Diagnosis]: [Supporting features]; [Refuting features]; [confirmed / provisional / rule out]
• [Substance-induced and medical contributors considered]: [Rationale and plan to clarify]

(Clearly label hypotheses versus confirmed diagnoses. Do not state a diagnosis as definitive if criteria are not met or information is missing.)

Diagnoses

1. [Primary psychiatric diagnosis (DSM/ICD)] [provisional if applicable]
2. [Comorbid psychiatric diagnoses] [provisional if applicable]
3. [Substance use diagnoses with severity]
4. [Relevant medical diagnoses affecting psychiatric treatment]
5. [Psychosocial stressors (Z-codes) as applicable]

Treatment Plan

(Organize by problem in descending order of severity. Document patient preferences and shared decision-making throughout.)

• [Problem 1]:
  • Goals: [Measurable short-term and longer-term goals]
  • Medications: [Medication name, dose, route, frequency; titration plan; target symptoms; expected timeline; risks discussed including black-box warnings if applicable; monitoring plan (labs, vitals, follow-up timing)] (If not prescribing, document rationale.)
  • Psychotherapy: [Modality, frequency, short-term goals; referrals placed; barriers if any]
  • Safety interventions: [Means counseling, safety plan elements, crisis resources provided] (Include if applicable to this problem.)
  • Care coordination: [PCP communication, specialty referrals, records requests]
• [Problem 2]: [Repeat structure as needed]

Disposition and Follow-up

• Disposition: [Outpatient / urgent follow-up / ED / hospital] with rationale
• Follow-up: [Specific interval and with whom]
• Return precautions: [Escalation instructions for worsening symptoms or safety concerns]
• Pending items: [Labs pending, records requested, collateral contacts planned]