The areas include history of present illness, psychiatric history, substance abuse history, medical history, review of systems, family history, person and social history,

Assessment Form

I selected an interview assessment tool that is specific to adults and was found from the Northeast Georgia Physicians Group (2019). What I like about the format of this interview assessment is the comparison between what the client reports and what the clinician observes. The client completes the sections designated for him, which,  inquires about mood, behavioral symptoms, mental health history, risk assessment, physical symptoms, medical history, nutrition, social history, social support, quality of life, education history, education history, job history, alcohol/ substance use, habits, goals for treatment. The clinician is then able to review what the client has reported and use that information to guide further questioning. 

Preceptor Evaluation

The interview assessment format my preceptor uses is one that is built into the computer system used at that facility so all assessments cover the necessary topics. The American Psychiatric Association released updated and revised guideline recommendations for the psychiatric evaluation of adults (Armstrong, 2016). These guidelines include nine areas of focus that complete a comprehensive psychiatric assessment for adults. The areas include history of present illness, psychiatric history, substance abuse history, medical history, review of systems, family history, person and social history, mental status exam, and impression and plan (APA, 2016). My preceptor’s assessments touch on all of these topics. 

Most Helpful Information

I believe the most helpful information obtained during an assessment is the psychiatric history. From this section a clinician gathers information about client’s “psychiatric illnesses and their course over the client’s lifetime, including symptoms and treatment” (Sadock, Sadock, & Ruiz, 2016, p. 198). One should closely evaluate the types of psychiatric treatments attempted, effects of treatment, and client compliance with previous treatment (Sadock, Sadock, & Ruiz, 2016). This gives the clinician a bases upon which to recommend future treatments and interventions (Sarin, Jain, & Murthy, 2018). 

References

American Psychiatric Association. (2016). Practice Guidelines for the Psychiatric Evaluation of 

Adults (3rded) . Retrieved from 

https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890426760

Armstrong, C. (2016). APA Updates Guidelines on Psychiatric Evaluation in Adults. American 

Family Physician, 94(1), 62–64. Retrieved from https://search-ebscohost-

com.ezp.waldenulibrary.org/login.aspx?direct=true&db=edswsc&AN=000378668900009&site=eds-live&scope=site

Northeast Georgia Physicians Group. (2019). Retrieved from 

https://www.ngpg.org/fullpanel/uploads/files/ngpg-psychiatry-new-patient-forms-adult.pdf

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: 

Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

Sarin, A., Jain, S., & Murthy, P. (2018). Turning the pages, or why history is important to 

psychiatry. Indian journal of psychiatry60(Suppl 2), S174–S176. doi:10.4103/psychiatry.IndianJPsychiatry_429_17

POST 2

  As a mental health provider, the advanced practice nurse will be tasked with evaluating new patient’s in inpatient and outpatient settings. The most important component of the initial evaluation of a mental health patient is the psychiatric interview (Sadock, Sadock, & Ruiz, 2014, p. 192). The psychiatric interview may contain many components which can include basic identifying information, chief complaints, psychosocial history, social history, medical assessment, and a mental status exam (MSE). The MSE is a key component of the psychiatric interview as it provides a description of the patient’s current mental status and helps to evaluate the patient’s behavior (Wheller, 2014, p. 102-3). I have developed a general interview format document that I can use to interview my patients. I have developed my interview guide from observing past preceptor’s interviews as well as academic resources. My current preceptors use a more informal process that they have developed over decades of practice. Having the organization of my interview format with the MSE at the end is the most useful part of my format since it allows me to observe the patient during the earlier sections of the interview to help decide which areas of the MSE to focus on at the end.

Interview Format Document

Patient name, date of birth, date of admission.

Legal Status: voluntary, involuntary, guardianship (name of guardian).

Referred by:

Primary language:

Chief complaints:

History of present illness:      

            Symptoms began:

            Precipitating factors:

Psychosocial history:

            Past psychiatric history:

                        Inpatient:

                        Outpatient:

                        Suicide attempts:

                        Drug/alcohol rehab:

                        Current Practitioners:

                                    Psychiatrist:

                                    Therapist:

                                    PCP:

Past/present psychiatric medications (medication, dose, frequency, currently taking, last dose, side effects):

Family psychiatric history:

            Maternal:

            Paternal:

            Siblings/offspring:

            Other relatives:

Current substance use:

            Cigarettes:     

            Alcohol/benzos:

            Marijuana:

            Heroin/opiates:

            Methamphetamines:

            Cocaine/crack:

            Prescription drugs:

            Other:

            Clean and sober for:

Social history:

            Work:

                        Employed: job type, employer

                        Unemployed, student, retired. Disabled

                        Financial status:

            Education:

            Family background:

                        Stable/unstable:

                        Religion/spiritual:

            Living arrangements:

            Relationship:

            Children/siblings:

            History of abuse:

            Legal history:

            Developmental factors:

                        Pregnancy:

                        Development:

                                    Academic:

                                    Behavioral:

Medical Assessment:

            Vital signs:

            Medical history—review of systems by exception:

                        Constitutional:

                        Respiratory:

                        Musculoskeletal:

                        Integumentary:

                        Neurological:

                        Eyes:

                        Genitourinary:

                        Immunologic:

                        Endocrine:

                        Ears/nose/mouth/throat:

                        Cardiac:

                        Gastrointestinal:

                        Hematologic/lymphatic:

            Allergies:

            Pain assessment:

            Surgical history:

Strengths and weaknesses:

            Family/social support:

            Finances:

            Coping skills:

Frustration tolerance:

            Motivation for treatment:

            Independent living skills:

            Other:

Mental Status Exam  

            Appearance:

            Attitude:

            Activity:

            Speech:

Mood:

            Affect:

            Symptoms:

                        Depression:

                        Mania:

                        Anxiety:

                        PTSD:

                        ADHD:

                        Sexual acting out:

                        Other:

            Thought process:

            Thought content:

            Suicidal ideation:

            Level of consciousness:

            Orientation:

            Memory:

                        Recent:

                        Remote:

            Concentration/attention span:

            Language:

            Information intelligence:

            Insight:

            Reliability:

            Gait/station:

            Muscle strength/tone:

            Abnormal movements:

            Additional info:

Interview Format Document my Preceptors Use

 For the current academic quarter, I have two preceptors that work in two different facilities. Both of my preceptors have been practicing for several decades, and while I have not worked extensively with them directly, I have witnessed their work during previous clinical rotations as well as from working with one of them at one of my jobs. After discussing with them about how they interview, they informed me that they do not utilize an interview guide per se, but that they follow a general path through the process that is fairly similar to my guide. Their years of experience allows them to be able to have a more dynamic process that they can use to tailor to the individual patient. During the initial assessment, a diagnosis may be made, as well. Using diagnostic interview tools like the diagnostic interview for anxiety, mood, and OCD and related neuropsychiatric disorders (DIAMOND), can be a useful addition to the psychiatric interview (Tolin et al., 2018).

The Element of My Interview Format That is Most Helpful

            I think that my interview format will be an effective method for psychiatric interviews in my practice. Having already performed interviews throughout my clinical experience, I find that having the structure of the interview with the MSE at the end is helpful. Having the MSE at the end allows me to analyze the behavior and responses of the patient during the initial portions of the interview and help me to focus on which areas of the MSE may require additional attention. I also believe that having the initial components of the interview will allow me to build rapport and trust with the patient so that they may be more forthcoming during the MSE. Having the patient trust the provider is an important aspect of an effective psychiatric interview (Kirkby & Grover, 2017).

References

Kirkby, K., & Grover, A. (2017). The Psychiatric Interview, Mental State Examination and Formulation. Foundations of Clinical Psychiatry Fourth Edition.

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

Tolin, D. F., Gilliam, C., Wootton, B. M., Bowe, W., Bragdon, L. B., Davis, E., … & Hallion, L. S. (2018). Psychometric properties of a structured diagnostic interview for DSM-5 anxiety, mood, and obsessive-compulsive and related disorders. Assessment25(1), 3-13.

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer.