Prolonged Grief Disorder Assessment Note

Date/Time: [Date and time of encounter]

Setting: [outpatient / inpatient / telehealth]

Visit Type: [PGD diagnostic assessment / consult / follow-up]

Clinician: [Name, credentials]

Reason for Visit

[Brief reason PGD is suspected, referral source if applicable, and patient's stated goals]

Information Sources

• [Patient interview] (Include interpreter use if applicable.)
• [Collateral contacts: name(s) and relationship(s)] (Include only if obtained and used.)
• [Records reviewed: source and date range] (Include only if applicable.)
• [Standardized measures administered] (List by name if applicable.)
• [Reliability statement] (Include only if factors affect reliability, e.g., cognitive impairment, language barriers, acute distress.)

Index Loss and Bereavement Timeline

Deceased and relationship: [Name/initials or descriptor per policy; relationship to patient]

Date of death: [Exact date or best approximation] (If uncertain, note whether diagnostic time threshold can be determined.)

Time since loss: [Calculated months/years since death] (Calculate explicitly.)

Circumstances of death: [expected illness / sudden natural / violent or traumatic / accident / suicide / homicide / other / unknown]

Patient's exposure: [present at death / witnessed aftermath / learned later / not exposed / unknown]

Bereavement course: [Brief chronology from acute grief to current pattern, noting key transitions, triggers, anniversaries]

Cultural and religious context: [Patient's cultural/religious mourning practices and expectations]

Norms vs. current presentation: [Explicit statement whether current grief intensity and duration exceed expected norms for patient's background, with rationale] (Do not assume; state reasoning.)

PGD Symptom Assessment

[Narrative summary of grief response including predominant emotions, cognitions, behaviors, and avoidance/approach patterns]

Core Symptoms

• Yearning/longing for the deceased: [present / absent]
  • Frequency/intensity: [Description]
  • Example: [Concrete patient example]
• Preoccupation with the deceased or circumstances of death: [present / absent]
  • Focus: [deceased / circumstances of death / both]
  • Frequency/intensity: [Description]
  • Example: [Concrete patient example]

Additional Symptoms

• Identity disruption: [present / absent] — Frequency: [Description] — Example: [Concrete example]
• Disbelief/difficulty accepting the death: [present / absent] — Frequency: [Description] — Example: [Concrete example]
• Avoidance of reminders: [present / absent] — Frequency: [Description] — Reminders avoided: [people / places / things / conversations] — Example: [Concrete example]
• Intense emotional pain: [present / absent] — Frequency: [Description] — Dominant emotions: [anger / bitterness / sorrow / guilt / shame] — Example: [Concrete example]
• Difficulty reintegrating into life: [present / absent] — Frequency: [Description] — Example: [Concrete example]
• Emotional numbness: [present / absent] — Frequency: [Description] — Example: [Concrete example]
• Sense that life is meaningless: [present / absent] — Frequency: [Description] — Example: [Concrete example]
• Loneliness/detachment: [present / absent] — Frequency: [Description] — Example: [Concrete example]

Duration

Symptom persistence: [Whether symptoms occur nearly every day and have been present at clinically significant intensity for at least the past month]

Bereavement time threshold met: [yes / no / uncertain] — Framework: [DSM-5-TR / ICD-11] (State explicitly which framework is applied and whether time-since-loss criterion is satisfied.)

Functional Impairment

• Work/school: [Specific impairments with examples]
• Social functioning: [Specific impairments with examples]
• Parenting/caregiving: [Specific impairments with examples] (Include only if applicable.)
• ADLs: [Sleep, eating, hygiene impairments with examples]
• Health behaviors: [Medical adherence, substance use, risk behaviors] (Include only if applicable.)

Standardized Measures

(Include this section only if standardized measures were administered. If none, omit entirely.)

• Measure: [Name and version, e.g., PG-13-R] — Administration: [interview / self-report / electronic] — Respondent: [patient / collateral]
• Total score: [Score] — Functional impairment item endorsed: [yes / no] — Interpretation: [Clinical interpretation; note cutoffs if applicable]
• Adjunct measures: [PHQ-9 / GAD-7 / PCL-5 / other] — Clinically significant findings: [Results, including suicidality item responses]

(Scores support but do not replace clinical assessment.)

Risk and Safety Assessment

• Suicide screening: [negative / positive / mixed] (Specify tool if used, or note direct questioning.)
• Current suicidal ideation: [none / passive / active] — Frequency: [Description] — Plan: [present / absent] — Intent: [present / absent] — Access to means: [Description] — Preparatory behaviors: [present / absent]
• Past attempts/self-harm: [History, dates, methods, lethality]
• Risk factors: [Recent loss, comorbid depression, PTSD, substance use, isolation, insomnia, hopelessness, other]
• Protective factors: [Supports, reasons for living, beliefs, responsibilities, therapeutic alliance, coping skills]
• Overall risk level: [low / moderate / high] — Rationale: [Brief clinical justification]
• Mitigation plan:
  • Safety plan: [Completed: yes / no] — [Key elements and warning signs]
  • Means safety counseling: [Completed: yes / no] — [Actions taken]
  • Crisis resources provided: [Resources given, e.g., 988, local crisis line]
  • Level of care: [outpatient / urgent follow-up / IOP / PHP / ED evaluation / inpatient] — Rationale: [Brief justification]
• Other safety concerns: [Homicide risk, vulnerability concerns, mandatory reporting] — Actions taken: [Description] (Include only if applicable.)

Relevant History

(Focus on information affecting differential diagnosis or treatment planning.)

• Psychiatric history: [Prior diagnoses, prior grief reactions, treatments and responses]
• Medical history: [Conditions affecting mood, sleep, or cognition]
• Medications: [Current psychotropics and relevant medications; adherence]
• Substance use: [Type, pattern, changes after loss]
• Social factors: [Living situation, supports, work/financial stressors]
• Strengths and supports: [Personal strengths, coping skills, supportive relationships]

Mental Status Examination

• Appearance: [Description]
• Behavior/psychomotor: [Including tearfulness, agitation, retardation, emotional numbing if present]
• Speech: [Rate, volume, prosody]
• Mood: [Patient-stated mood]
• Affect: [Range, intensity, congruence, lability]
• Thought process: [coherent / circumstantial / tangential / ruminative]
• Thought content: [Grief themes, guilt, hopelessness, SI/HI, preoccupations]
• Perceptions: [Hallucinations, illusions, or none] (Note grief-related perceptual experiences if present.)
• Cognition: [Orientation, attention, memory as observed]
• Insight: [Description]
• Judgment: [Description]

Assessment

Clinical summary: [Patient description, the loss, time since loss, key symptoms, functional impairment, relevant comorbidities, risk level] (One concise paragraph.)

Diagnostic determination: [PGD criteria met / not met / probable / rule-out] — Framework: [DSM-5-TR / ICD-11] — Rationale: [Explicit reasoning addressing time since loss, core and additional symptoms, functional impairment, and cultural context] (If time criterion not met, state clearly and document monitoring plan.)

Differential Diagnosis

• Major depressive disorder: [Distinguishing rationale]
• PTSD: [Distinguishing rationale] (Include if traumatic death.)
• Adjustment disorder: [Distinguishing rationale]
• Anxiety disorders: [Distinguishing rationale]
• Substance-induced disorder: [Distinguishing rationale] (Include if applicable.)
• Normal/acute grief within cultural norms: [Distinguishing rationale]

Diagnoses

• Primary diagnosis: [Diagnosis]
• Comorbid diagnoses: [Diagnoses] (Include only if present.)

Plan

(Organize by problem, highest acuity first.)

Prolonged Grief

• Psychotherapy: [Grief-focused therapy modality and referral details] (First-line treatment.)
• Grief support resources: [Support group, peer support, community or spiritual resources]
• Measurement-based follow-up: [Measure to repeat, interval, method]
• Treatment goals: [Specific, observable goals for reintegration, reduced avoidance, improved functioning]

Comorbid Conditions

(Include only if comorbidities present.)

• Condition: [Diagnosis] — Intervention: [Therapy modality or other treatment] — Target symptoms: [Specific symptoms addressed]
• Medication: [Agent, dose, frequency] — Target symptoms: [Depression, anxiety, insomnia, PTSD symptoms] — Rationale: [Brief benefit-risk discussion] (Clarify medication targets comorbidity, not grief itself.)

Safety Plan

(Include if elevated risk identified.)

• Safety plan elements: [Key components completed, patient copy provided]
• Means safety: [Actions taken to limit access]
• Crisis resources: [Resources and instructions provided]
• Follow-up timing: [Interval based on risk level]

Referrals and Coordination

• [Referrals: psychiatry, psychology, grief specialist, social work, primary care, spiritual care as indicated]
• [Care coordination and information sharing with consent]

Follow-Up

Next appointment: [Timing and modality] — Contingency instructions: [What to do if symptoms worsen before follow-up]

Missing essential information: [What is missing, barrier, and plan to obtain] (Include only if essential data could not be obtained, especially time since loss or safety information.)