Psychiatry — Comprehensive Psychiatric Evaluation Template
The Comprehensive Psychiatric Evaluation Template is an essential tool for psychiatrists, psychiatric nurse practitioners, and mental health professionals conducting initial diagnostic assessments. This detailed template provides systematic documentation of psychiatric history, mental status examination, risk assessment, diagnostic formulation, and treatment planning required for the first psychiatric encounter. The template follows DSM-5 diagnostic criteria and includes sections for chief complaint, history of present illness with detailed symptom assessment, past psychiatric history including previous diagnoses and treatments, substance use history, trauma history, complete mental status examination, suicide and violence risk assessment, diagnostic impressions with ICD-10 codes, initial treatment plan including psychotherapy modality and medication considerations, safety planning, and follow-up scheduling. This comprehensive structure supports quality psychiatric care, ensures thorough risk assessment documentation, meets billing requirements for psychiatric diagnostic evaluation (CPT 90791-90792), facilitates treatment continuity across providers, and establishes baseline functioning for outcome measurement. Ideal for outpatient psychiatry clinics, community mental health centers, hospital psychiatric consult services, and private practice mental health providers.
Template
Chief Complaint
Patient-stated reason for evaluation.
History of Present Illness
Onset, duration, context, precipitating factors, prior episodes, treatments, response.
Psychiatric History
Diagnoses, hospitalizations, suicide attempts, self-harm, medications/response, therapy.
Substance Use
Alcohol, cannabis, stimulants, opioids, sedatives; frequency, quantity, impact.
Social/Developmental History
Family, housing, employment, education, trauma, legal, supports.
Mental Status Exam (MSE)
Appearance/behavior, speech, mood/affect, thought process/content, perception, cognition, insight/judgment.
Risk Assessment
Suicidal ideation, homicidal ideation, intent/plan, access to means, protective factors, safety plan.
Assessment & Plan
Working diagnoses, initial pharmacotherapy/therapy, labs as indicated, safety planning, follow-up.
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