Introduction

The secret to a coherent and engaging presentation:

1. include pertinent elements
   

2. exclude impertinent points
   

3. set the foundation on to which you are going to layer the clinical story
   

4. offer a “syndromal” history of present illness (HPI)
   

5. come up with no surprises in your formulation or diagnosis, as they relate to all that preceded
   

The mental health history should include: demographics, chief complaint, history of the present illness, past psychiatric history, past medical history and review of systems, past personal history, and family history. A mental status exam, physical exam, impression and plan are also included in the initial patient evaluation. Further elaboration of each of these is as follows:

Demographics (Identifying Information)

Age, sex, religion, marital status, means of support, educational level, where and when with whom is the patient living and how the patient was brought to the hospital. Include primary psychiatric diagnosis if known, current care in one line and number of psychiatric admissions (with number of your own hospital’s admissions).

Chief Complaint

A brief statement in the patient’s words or behavior that best illustrates the reason for admission.

History of Present Illness

A chronological development of symptoms portrayed in a syndromal pattern beginning with the patients last period of usual functioning. This should include pertinent positives and negatives to illustrate diagnoses being considered or ruled out, present medications, outpatient therapy and drug and/or alcohol use.

Past Mental Health History

This should begin with the last psychiatric hospitalization and include all past psychiatric hospitalizations, dates of admission, length of stays, chief complaint on each admission, and response to various interventions (be specific). Significant outpatient therapy and intervention should also be included in a chronological fashion as well as past history of alcohol and drug use.

Past Medical History

The should include pertinent positives and negatives to include: hypertension, diabetes, tuberculosis, hepatitis, AIDS, epilepsy, heart disease, liver disease, kidney disease, medical hospitalizations, surgical procedures, present medications, and allergies/drug sensitivities.

Past Personal History

Beginning with the date of birth describe chronological development along three lines: a) intimate relationships to include family and sexual/marital history, b) social relations to include friends, acquaintances and ability to interact with others, and c) sublimatory capacity through a description of school and work. The quality of the above relationships is investigated in this part of the history. In addition, a history of separation, abuse, early trauma and a description of family members is also included.

Family Medical and Mental Health History

An elaboration of any of the following, biological relatives: bipolar disorder, depression, Alzheimer’s, schizophrenia, alcohol or drug use and abuse, antisocial, gives of people or borderline personality disorders, suicide (violent or nonviolent), and psychiatric hospitalizations. In addition, response of any of the above two previous interventions should be noted.

Mental Status Exam (MSE)

Please present a coherent overview of the patient’s mental status, so as to include pertinent positive and negative findings. This does not necessarily represent a mental status during a single point in time, but rather may include elements over a discrete period. The MSE describes present symptoms, signs and behavior only. It’s basic format consists of: general appearance (hygiene, manner, dress, movements, attitude, etc.) speech (rate, rhythm, pressure, etc.) state of consciousness and orientation affect/mood stream of consciousness (loosening of associations, flight of ideas, circumstantiality, tangentiality) content of consciousness (delusions, ideas of reference, paranoid ideation, suicidal ideation, etc.) perceptual disturbances (delusions, hallucinations, etc.) memory (immediate, recent, remote) concentration intelligence (fund of knowledge, calculations, etc.) abstraction (proverbs, similarities) insight (general and specific) judgment (by history and by formal testing)

Impression

The impression should include a DSM-IV five-axis diagnosis as well as a brief dynamic or psychosocial formulation.