Psychiatry Resources

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Headshot of Kimberly Beine, MD · CBL Director
Kimberly Beine
MD · CBL Director
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Table of Contents

These resources will help you when you encounter patients with behavioral health needs, whether in a psychiatry setting or in a different clinical setting (e.g., family medicine, internal medicine, emergency medicine).

Psychiatric history and physical 

  • Identifying information or demographic data

    At minimum name and date of birth, single/married/divorced, race, reference to any prior inpatient or outpatient psychiatric treatment.

  • Chief concern or chief complaint

    Best if in patient’s own words (a simple sentence in their own words why they are there for help).

  • History of present illness

    In psychiatry, a concise presentation.

  • Restatement of chief concern. Include precipitating event/stressors.
  • Duration of chief concern. (Usually start chronologically when symptoms or signs began.)
  • Symptoms in support of the DSM-5 TR diagnosis.
  • Pertinent negatives.
  • (Any other psychiatric disorders).
  • Mention of any substance use and alcohol use (if pertinent to HPI or fill in below).
  • Any concern of a medical disorder contributing.(Separate paragraph for each disorder.) 

  • Past psychiatric history

    Include:

  • Previous treatment (including psychiatric hospitalizations), specifically medications, psychotherapies, and others.
  • Report names of prior treatment providers if possible.
  • In reporting of previous psychiatric medications, include names, dose, duration of use, effects, and side effects (if known).
  • Any previous self-harm.
  • Any previous suicide attempt.
  • Any previous aggressive or impulsive behaviors, or harm to others.

  • Substance use history

    Any current use, quantify/duration, and past use (quantify, duration for each).

  • Past medical history

    Very much like any other history and physical. Includes illnesses, current medications, known drug allergies, surgeries. Emphasis on any neurological problems, including any reported history of head injuries or blackouts. 

  • Family medical history

    To include all illnesses with special emphasis on psychiatric diagnosis and any deaths from suicide/homicide. 

  • Social history/developmental history

    Depending on patient’s age:

  • Gestational and birth history 
  • Developmental milestones 
  • Family history: May be helpful to inquire about parents, their occupational history, home life growing up.
  • School history 
  • Occupational history 
  • Relationship history 
  • Psychological and physical trauma 
  • Military history 
  • Legal history 
  • Current living situation 

  • Physical exam

    Include:

  • Vital signs 
  • PE
  • Remainder of physical exam

  • Mental status exam

    Include:

  • Appearance 
  • Speech 
  • Emotion: Mood and affect 
  • Suicidal and/or homicidal ideation, intent, or plans
  • Perception 
  • Thought process
  • Thought content 
  • Insight and judgement 
  • Cognitive sensorium, memory, concentration/attention, orientation, visuospatial 

  • Clinical formulation

    This is how we synthesize all of the past history and current observations. It should provide understanding of the person in biological, psychological and social terms. It ultimately leads to a diagnosis and supports a plan of treatment)

Review of psychiatric disorders

To be considered for use when not already covered in the patient’s HPI, these are suggestions and not a complete list. The childhood disorders are reviewed with parents and are not included here. 

Anxiety symptoms

Have you had trouble going out because of panic attacks? 
Do you tend to worry more than others?
Is it hard to fall asleep because of worry? 
Do your muscles feel tense during the day? 
Are you restless more than others?
Do you avoid social situations because you are anxious how others see you?
Is it hard to be away from loved ones? 
Are there situations when you find it difficult to speak? 

Behavior symptoms

Is it difficult to complete tasks?
Do you speak out of turn?
When doing a project do you have to regroup frequently?

Bipolar disorder

Does your mood have times when it changes for no reason?
Do you have spending sprees despite not having any money? 
What’s the minimum amount of sleep you need, and for how long can you keep that up? 
Do others mention that you talk too fast?
Do you find yourself getting easily frustrated with others for no reason?

Cognitive

Have you concerns about your memory?
Do others bring up concerns about your memory?
Is it hard to remember the steps in doing routine projects?

Depression

Is it hard to enjoy activities that you previously enjoyed?
What brings you pleasure?
Any changes in sleep?
Any changes in appetite?
Trouble with concentration? 
Feelings of guilt?
Feelings of hopelessness? 
Easy crying spells? 
During the month, are there changes in your mood before your menses?

Eating disorders

Do you try to keep losing weight despite others concerns about your health? 
How would you describe your physical appearance? 

OCD

Do you have times when you repeat the same thing in your mind and feel anxious?
Do you feel urge to pick your skin?
Do you feel urge to pull your hair?

Psychotic disorder

Are there times when you worry someone is trying to cause trouble for you?
Have you had times when you hear conversations, and no one seems to be around? 
Do you have any special talents that no one else has?
Does it feel like someone is trying to control your mind? 

Personality disorder

Do you keep losing friendships?
Is it hard to keep a job?
Have you had frequent run-ins with the legal system?
Is it hard to make decisions?
Do you have any magical powers? 
Do you prefer your own company?

Sleep disorder

Do you wake up more tired than when you went to bed?
Do others say you snore?
Are you a person that prefers to be up all night and then can’t make it to work/school?

Substance use disorder

Do you try to stop using X and have not been able?  

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