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Psychiatric Interview?Template

 

Preparing the Assignment

Follow these guidelines when completing each component of the assignment. Contact your course faculty if you have questions.

General Instructions

  1. Download the Psychiatric Interview Template.
  2. Watch the Psychiatric Interview Recording and complete the required psychiatric interview documentation. Client age and allergies have been completed.

Include the following elements:

  1. History of present illness (HPI)   
    • Include the chief complaint in quotation marks 
    • List only HPI data 
    • Use appropriate terminology 
    • Provide support from an appropriate scholarly source or textbook to support content and terminology
    • Provide information that is understandable, well-organized, and easy to follow
  2. Medications
    • Provide all current medication information
    • Include all criteria from the medication table
    • Use appropriate medical terminology
    • Provide information that is understandable, well-organized, and easy to follow
  3. Past psychiatric history 
    • Include entire past psychiatric history  
    • Address all criteria listed on the template    
    • Use appropriate terminology 
    • Provide support from an appropriate scholarly source or textbook to support content and terminology
    • Provide information that is understandable, well-organized, and easy to follow 
  4. Medical history
  5. Include all relevant medical information
  6. Address all criteria listed on the template
  7. Use appropriate terminology
  8. Provide support from an appropriate scholarly source or textbook to support content and terminology
  9. Provide information that is understandable, well-organized, and easy to follow
  10. Family History
  11. Include all pertinent family history
  12. Address all criteria listed on the template
  13. Use appropriate terminology
  14. Provide support from an appropriate scholarly source or textbook to support content and terminology
  15. Provide information that is understandable, well-organized, and easy to follow
  16. Social History
  17. Include all relevant information from the social history 
  18. Address all criteria listed on the template    
  19. Use appropriate terminology 
  20. Provide support from an appropriate scholarly source or textbook to support content and terminology
  21. Provide information that is understandable, well-organized, and easy to follow 
  22. Review of systems (ROS)
  23. Address all ROS criteria listed on the template
  24. Use appropriate terminology
  25. Provide support from an appropriate scholarly source or textbook to support content and terminology
  26. Provide information that is understandable, well-organized, and easy to follow
  27. Mental status examination (MSE)
  28. Include each element of the MSE 
  29. Address all criteria listed on the template    
  30. Use appropriate terminology
  31. Provide support from an appropriate scholarly source or textbook to support content and terminology
  32. Provide information that is understandable, well-organized, and easy to follow 
  33. List items not addressed during the interview and discuss whether listed items were appropriately omitted or should be included. Cite a reference to support the listed items.
  34. Formatting
  35. Carlat’s (2017) textbook is used to support terminology and section content
  36. Sources represent a logical link between the source content and the interview documentation
  37. In-text citations match listed references
  38. Direct quotes are not used  

Submit your completed template to the Week 6 Dropbox.  

https://www.kaltura.com/index.php/extwidget/preview/partner_id/2363221/uiconf_id/49982073/entry_id/1_86pau68q/embed/iframe? 

Name:

Psychiatric Interview Template

S: Subjective

(Information the client or representative told you)

Initials: Click or tap here to enter text.

Age: 54

Gender: Click or tap here to enter text.

Include vital signs if provided . Document not provided if not available.

Height

Weight

Allergies (and reaction)
Click or tap here to enter text. Click or tap here to enter text.

Medication: none

Food: shellfish-anaphylaxis

Environment: none

History of Present Illness (HPI)

Chief Complaint (CC)

CC is a BRIEF statement identifying why the client is here – in the patient’s own words – for instance "I have been feeling depressed," NOT "symptoms of depression for 3 weeks.” History of Present Illness (HPI)

(1) Develops illness narrative ( cogent story with clear chronology, not a list of symptoms), and

(2) includes specific details of symptoms, and the impact of these symptoms on daily life.

HPI

Click or tap here to enter text.

Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Medication

(Rx, OTC, or Homeopathic)

Dosage

Frequency

Length of Time Used

Reason for Use

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Past Psychiatric History – Includes all previous mental health psychotherapy and medication management. Be as descriptive as possible. Include type of provider, name if provided, year(s) of treatment, types of services received, history of trauma, self-harm or harm to others.

Medical History (PMHx) – Includes active medical problems (currently getting managed) and past medical problems (no longer needing any intervention), hospitalizations, and surgeries. Depending on the CC, more info may be needed.

Family History (Fam Hx) – History i ncludes but is not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents (if information was provided), siblings, and children. Include grandchildren if pertinent.

Social History (Soc Hx) – History includes but not limited to education, occupation, current employment (If not currently working, when was last time client was employed and what was the reason for stopping?), current living arrangements, hobbies, relationship status, tobacco, alcohol and other substance use including cannabis or CBD use, legal issues and any other pertinent data.

Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details. Include all provided information. If not assessed leave blank or select “other” if not applicable to the client.

Constitutional

If patient denies all symptoms for this system, check here: ☐

Skin

If patient denies all symptoms for this system, check here: ☐

HEENT

If patient denies all symptoms for this system, check here: ☐

☐Fatigue Click or tap here to enter text.

☐Weakness Click or tap here to enter text.

☐Fever/Chills Click or tap here to enter text.

☐Weight Gain Click or tap here to enter text.

☐Weight Loss Click or tap here to enter text.

☐Trouble Sleeping Click or tap here to enter text.

☐Night Sweats Click or tap here to enter text.

☐Other:

Click or tap here to enter text.

☐Rashes Click or tap here to enter text.

☐Other:

Click or tap here to enter text.

☐Diplopia Click or tap here to enter text.

☐Vision changes Click or tap here to enter text.

☐Photophobia Click or tap here to enter text.

☐Earache Click or tap here to enter text.

☐Tinnitus Click or tap here to enter text.

☐Epistaxis Click or tap here to enter text.

☐Vertigo Click or tap here to enter text.

☐Hearing Changes Click or tap here to enter text.

☐Other:

Click or tap here to enter text.

Respiratory

If patient denies all symptoms for this system, check here: ☐

Neuro

If patient denies all symptoms for this system, check here: ☐

Cardiac

If patient denies all symptoms for this system, check here: ☐

MSK

If patient denies all symptoms for this system, check here: ☐

☐Cough Click or tap here to enter text.

☐Hemoptysis Click or tap here to enter text.

☐Dyspnea Click or tap here to enter text.

☐Wheezing Click or tap here to enter text.

☐Pain on Inspiration Click or tap here to enter text.

☐Snoring : Click or tap here to enter text.

☐Other:

Click or tap here to enter text.

☐Syncope or Lightheadedness Click or tap here to enter text.

☐Headache Click or tap here to enter text.

☐Numbness Click or tap here to enter text.

☐Tingling Click or tap here to enter text.

☐Sensation Changes

Choose an item.

☐Speech Deficits Click or tap here to enter text.

☐Other: Click or tap here to enter text.

☐Chest pain Click or tap here to enter text.

☐SOB Click or tap here to enter text.

Previous cardiac history Click or tap here to enter text.

☐Other: Click or tap here to enter text.

☐Pain Click or tap here to enter text.

☐Limited ROM Choose an item.

☐Redness Click or tap here to enter text.

☐ involuntary movements Click or tap here to enter text.

☐Other: Click or tap here to enter text.

Hematology/Lymphatics

If patient denies all symptoms for this system, check here: ☐

GI

If patient denies all symptoms for this system, check here: ☐

GU

If patient denies all symptoms for this system, check here: ☐

Endocrine

If patient denies all symptoms for this system, check here: ☐

☐Anemia Click or tap here to enter text.

☐ Other Click or tap here to enter text.

☐Nausea/Vomiting Click or tap here to enter text.

☐Dysphasia Click or tap here to enter text.

☐Diarrhea Click or tap here to enter text.

☐Appetite Change Click or tap here to enter text.

☐Heartburn Click or tap here to enter text.

☐Abdominal Pain Click or tap here to enter text.

Click or tap here to enter text.

☒Other: Click or tap here to enter text.

☐Urgency Click or tap here to enter text.

☐Polyuria Click or tap here to enter text.

☐Nocturia Click or tap here to enter text.

☐Incontinence Click or tap here to enter text.

☐Other: Click or tap here to enter text.

☐ Increased appetite Click or tap here to enter text.

☐ Increased thirst Click or tap here to enter text.

☐ Thyroid disorder Click or tap here to enter text.

☐ Heat/cold intolerance Click or tap here to enter text.

☐ Excessive sweating Click or tap here to enter text.

☐ Diabetes Click or tap here to enter text.

☐ Other Click or tap here to enter text.

O: Objective

Document pertinent positive and negative assessment findings. Pertinent positive are the “abnormal” findings and pertinent “negative” are the expected normal findings. Separate the assessment findings accordingly and be detailed. Use appropriate terminology.

Mental status exam

Findings

Appearance

Choose an item.

Click or tap here to enter text.

Behavior

Choose an item.

Click or tap here to enter text.

Speech

Choose an item.

Click or tap here to enter text.

Affect

Choose an item.

Click or tap here to enter text.

Thought Process

Choose an item.

Click or tap here to enter text.

Thought Content

Choose an item.

Click or tap here to enter text.

Attention and Concentration

Choose an item.

Click or tap here to enter text.

Memory

Choose an item.

Click or tap here to enter text.

Orientation

Choose an item.

Click or tap here to enter text.

Insight

Choose an item.

Click or tap here to enter text.

Judgement

Choose an item.

Click or tap here to enter text.

List items that were not addressed in the interview . Discuss whether these items are appropriately omitted or should be included.

Click or tap here to enter text.

References

Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct current APA edition formatting. You may use your textbooks as a secondary reference, but you are required to include an EBP journal article, not a web-based reference.

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