httpsCOMPREHENSIVE INITIAL PSYCHIATRIC AND CLINICAL PSYCHOLOGY EVALUATION [Blank plain-text template for basic EHR free-text fields. ASCII only - safe for legacy systems. Lines in square brackets are guidance - delete before saving. Adapt to your setting, payer and regulator.] 1. IDENTIFYING AND ADMINISTRATIVE DATA ------------------------------------------------------- Patient name: ______________________________ File / MRN (Medical Record Number): ______________________________ DOB (Date of Birth) / Age: ______________________________ Sex / Gender: ______________________________ Marital status / Dependants: ______________________________ Occupation: ______________________________ Nationality / Residence: ______________________________ Referral source and reason: ______________________________ Date(s) of assessment: ______________________________ Clinician (name, title, licence no.): ______________________________ Informants: ______________________________ Consent: ______________________________ 2. CC (CHIEF COMPLAINT) - PATIENT'S VERBATIM WORDS ------------------------------------------------------- [Record verbatim, in quotation marks.] CC: ______________________________ 3. HPI (HISTORY OF PRESENT ILLNESS) ------------------------------------------------------- [Onset, course, duration; core symptoms; precipitants; severity and functional impact; risk-relevant content; treatments tried; pertinent negatives (mania, psychosis, panic).] 4. PSYCHIATRIC ROS (REVIEW OF SYSTEMS) ------------------------------------------------------- [Screen and record positive/negative for each domain.] - Depression: ______________________________ - Anxiety / Panic: ______________________________ - Mania / Hypomania: ______________________________ - Psychosis: ______________________________ - OCD (Obsessive-Compulsive Disorder): ______________________________ - Trauma / PTSD (Post-Traumatic Stress Disorder): ______________________________ - Eating: ______________________________ - Sleep: ______________________________ 5. PAST PSYCHIATRIC HX (HISTORY) ------------------------------------------------------- [Prior diagnoses; psychotherapy and medication trials with response/adherence; hospitalisations; ED (Emergency Department) contacts; past suicide attempts and NSSI (Non-Suicidal Self-Injury).] Summary: ______________________________ 6. SUBSTANCE USE HX ------------------------------------------------------- - EtOH (alcohol) - pattern, units/week, AUDIT-C (Alcohol Use Disorders Identification Test-Consumption) score: ______________________________ - Nicotine / vaping: ______________________________ - Caffeine: ______________________________ - Illicit substances / prescription misuse: ______________________________ - Past SUD (Substance Use Disorder) treatment: ______________________________ 7. PMHX (PAST MEDICAL HISTORY), MEDICATIONS AND ALLERGIES ------------------------------------------------------- PMHx: ______________________________ Current medications (incl. OTC (Over-The-Counter)): ______________________________ Allergies: ______________________________ Investigations requested / pending: ______________________________ 8. FHX (FAMILY HISTORY) ------------------------------------------------------- [Psychiatric illness, suicide, substance use, relevant medical conditions in first- and second-degree relatives.] Summary: ______________________________ 9. DEVELOPMENTAL AND SOCIAL HX ------------------------------------------------------- - Birth / development / childhood environment: ______________________________ - Education and occupational history: ______________________________ - Relationships and family: ______________________________ - Housing and finances: ______________________________ - Forensic / legal: ______________________________ - Trauma history: ______________________________ - Religion / spirituality: ______________________________ - Lifestyle and exercise: ______________________________ 10. MSE (MENTAL STATUS EXAMINATION) ------------------------------------------------------- - Appearance and Behaviour: ______________________________ - Speech: ______________________________ - Mood and Affect: ______________________________ - Perception: ______________________________ - Thought Content (incl. SI/HI (Suicidal/Homicidal Ideation)): ______________________________ - Thought Form / Process: ______________________________ - Cognition (incl. screen, e.g. MoCA (Montreal Cognitive Assessment)): ______________________________ - Insight: ______________________________ - Judgement: ______________________________ 11. MBC (MEASUREMENT-BASED CARE) - BASELINE SCORES ------------------------------------------------------- [Format: Measure: score - severity band - repeat cadence] - PHQ-9 (Patient Health Questionnaire-9): ______________________________ - GAD-7 (Generalised Anxiety Disorder-7): ______________________________ - WSAS (Work and Social Adjustment Scale): ______________________________ - ISI (Insomnia Severity Index): ______________________________ - Other (e.g. PCL-5 (PTSD Checklist for DSM-5), AUDIT-C): ______________________________ Reliable-change convention: a reduction of >=5 points on PHQ-9 or GAD-7 is treated as reliable improvement. 12. RISK ASSESSMENT ------------------------------------------------------- 12.1 C-SSRS (COLUMBIA-SUICIDE SEVERITY RATING SCALE) - SCREENER SUMMARY - Wish to be dead: ______________________________ - Non-specific active suicidal thoughts: ______________________________ - Ideation with method / intent / plan: ______________________________ - Suicidal behaviour (lifetime / past 3 months): ______________________________ 12.2 RISK AND PROTECTIVE FACTORS - Static factors: ______________________________ - Dynamic (modifiable) factors: ______________________________ - Protective factors: ______________________________ 12.3 RISK FORMULATION AND LEVEL [Synthesise: current level (low / moderate / high), rationale, risk to others, safeguarding, review interval and escalation criteria.] Formulation: ______________________________ 12.4 SPI (STANLEY-BROWN SAFETY PLANNING INTERVENTION) - 6 STEPS - Step 1 - Warning signs of an impending crisis: ______________________________ - Step 2 - Internal coping strategies: ______________________________ - Step 3 - Social contacts and settings that provide distraction: ______________________________ - Step 4 - Family members or friends who may help resolve a crisis: ______________________________ - Step 5 - Professionals and agencies to contact: ______________________________ - Step 6 - Making the environment safer (means-safety counselling): ______________________________ 13. BIOPSYCHOSOCIAL FORMULATION - 4PS ------------------------------------------------------- [4Ps = Predisposing, Precipitating, Perpetuating, Protective; each across Biological, Psychological and Social domains.] PREDISPOSING: - Biological: ______________________________ - Psychological: ______________________________ - Social: ______________________________ PRECIPITATING: - Biological: ______________________________ - Psychological: ______________________________ - Social: ______________________________ PERPETUATING: - Biological: ______________________________ - Psychological: ______________________________ - Social: ______________________________ PROTECTIVE: - Biological: ______________________________ - Psychological: ______________________________ - Social: ______________________________ NARRATIVE SYNTHESIS: [Two to four sentences: how the factors interact to produce and maintain the presentation; identify the primary treatment targets (usually the perpetuating factors).] 14. CULTURAL FORMULATION - CFI (CULTURAL FORMULATION INTERVIEW, DSM-5-TR) ------------------------------------------------------- - Cultural definition of the problem: ______________________________ - Perceived causes, context and supports: ______________________________ - Self-coping and past help-seeking: ______________________________ - Current help-seeking preferences: ______________________________ 15. DIAGNOSIS - DSM-5-TR WITH ICD-10-CM CODES ------------------------------------------------------- [DSM-5-TR = Diagnostic and Statistical Manual of Mental Disorders, 5th ed., Text Revision; ICD-10-CM = International Classification of Diseases, 10th Revision, Clinical Modification.] - Principal diagnosis (code): ______________________________ - Comorbid diagnoses (codes): ______________________________ - Provisional / rule-outs and differentials: ______________________________ - Psychosocial stressor Z-codes: ______________________________ 16. TREATMENT PLAN ------------------------------------------------------- 16.1 PROBLEM LIST ______________________________ 16.2 SMART GOALS (SPECIFIC, MEASURABLE, ACHIEVABLE, RELEVANT, TIME-BOUND) - G1: ______________________________ - G2: ______________________________ - G3: ______________________________ 16.3 INTERVENTIONS - Psychological therapy (modality, dose, techniques): ______________________________ - Sleep / lifestyle: ______________________________ - Exercise prescription: ______________________________ - Pharmacotherapy pathway / referral (shared decision-making): ______________________________ - Family / systemic: ______________________________ - Liaison and referrals: ______________________________ 16.4 MBC SCHEDULE, SAFETY AND REVIEW - MBC schedule and reliable-change threshold: ______________________________ - Safety plan status and escalation criteria: ______________________________ - Review date: ______________________________ 17. CLINICIAN ATTESTATION ------------------------------------------------------- I confirm that this report reflects my clinical assessment on the date stated and that the patient was involved in decisions about the plan. Clinician name and title: ______________________________ Licence No.: ______________________________ Signature / Date: ______________________________ APPENDIX A - POST-SESSION PROGRESS NOTE (GIRP+ FORMAT) ------------------------------------------------------- [GIRP+ = Goal, Intervention, Response, Plan, extended with Data, MBC scores and an explicit Risk line every session. Golden thread: every note links to a treatment-plan goal.] Session no. / Date / Duration / Modality: ______________________________ G (Goal addressed - from treatment plan): ______________________________ D (Data - patient-reported and clinician-observed): ______________________________ I (Intervention - name the specific technique): ______________________________ R (Response to the intervention): ______________________________ A (Assessment - progress, interpretation, MBC scores and trend): ______________________________ Risk (SI/HI screen; safety plan status): ______________________________ P (Plan - next steps, homework, referrals, next appointment): ______________________________