Psychiatric evaluations vary according to their purpose. This guide is intended primarily for general, emergency, and consultation evaluations for clinical purposes.

1. Establish aims of the evaluation.

• Assess and enhance safety and coordinate care.
• Establish whether a mental disorder is present.
• Collect data sufficient to support a differential diagnosis, including information from collateral sources.
• Collaborate with the patient to develop an initial treatment plan.
• Identify longer term issues for follow-up.

3. For consultations:

• Clarify the scope and purpose of the evaluation before proceeding with consultations relating to specific legal, administrative, or nonclinical questions, and discuss limits of confidentiality with the patient and the requester of the consultation.
• Provide clear and specific answers to (usually narrow) questions from the requester of a clinical consultation.
• Respect the patient’s relationship with the primary clinician and encourage positive resolution of conflicts.

1. Adjust goals and evaluative approaches to the setting.

Settings include inpatient, outpatient, home, emergency, school, residential treatment, skilled nursing, long-term care, and correctional and other forensic settings.

2. Consider if the setting meets the needs of the patient.

For patients seen longitudinally, continually reassess to determine the appropriate level of care.

3. Document factors of the setting that may limit the evaluation.

Such factors may include lower level and quality of observation, compromised privacy, unavailability of interpreters for patients with limited English proficiency, unavailability of medical evaluations and diagnostic tests, and compromised safety and confidentiality.

4. Use inpatient settings to optimize safety, provide intensive and continuous observation, and provide multidisciplinary treatment and collaborative decision making.

It is important to assess the patient’s current living environment on admission and identify resources to optimize care after discharge.

5. Use outpatient settings to provide greater patient autonomy and longitudinal perspective on the patientâ??s symptoms.

• Consider helping the patient to obtain a primary care physician to enhance attention to co-occurring general medical conditions.
• With the patient’s permission, involve the family and significant others, but be aware of conflicts that may interfere with support.
• Consider if observation from one-to-one interviews can be complemented by observations of the patient in a group setting.

2. Generally, consider the domains in Table 1 systematically.

3. Also consider aspects of the patient's developmental history that may be associated with an increased risk of later psychiatric illness (Table 2).

1. Methods of Obtaining Information

The psychiatrist’s primary assessment tool is the direct face-to-face interview of the patient.

• Facilitate the patient’s telling of his or her story.
• Consider time constraints. Attend to the patient’s most pressing concerns.
• Use a combination of open-ended, empathic questioning and structured, systematic inquiry (e.g., about substance use, traumatic life events).
• Give high priority to assessment of safety and identification of signs, symptoms, and disorders requiring urgent treatment.
• Consider sociocultural issues.
• Use professionally trained interpreters with mental health experience, when available, for evaluation of patients with limited English proficiency and those who are deaf or have severely limited hearing and who know a sign language.

Consider using collateral sources such as family members, other important people in the patient’s life, and records of prior general medical and psychiatric treatment.

• These sources of information are frequently useful, especially for patients with impaired insight, impaired function, or unstable behavior.
• Collateral sources may provide important information about the patient’s premorbid personality, illness course, and reasons for the evaluation.
• Confidentiality should be respected. The psychiatrist may listen to input from collateral sources and ask questions without conveying confidential information to others.

Consider using structured interviews, psychological tests, forms, questionnaires, and rating scales.

• These tools can be useful for establishing a diagnosis, measuring social or occupational function, and monitoring changes in symptom severity or side effects over time during treatment.
• These tools vary as to their reliability and validity. Sociocultural and other issues may bias results and interpretation of results.
• Many clinical rating scales are available in APA’s Handbook of Psychiatric Measures, published in 2000 by American Psychiatric Publishing, Inc.

Consider whether modifications in the evaluation are needed if the patient exhibits agitation or aggressive behavior.

• Attend to safety considerations (e.g., office configuration and environment, availability of and mechanisms for summoning backup personnel).
• Use a nonconfrontational approach that respects and addresses the patient’s stated concerns, feelings, and affect.
• Remain alert for signs that agitation is escalating (e.g., increased body movements or pacing, clenched fists, verbal threats, or increasing verbal volume) and that the interview style or timing may require adjusting.
• Consider whether administration of psychotropic medications or judicious use of one-to-one nursing care or seclusion or restraint may be needed to enhance the safety of the patient and others or to permit essential physical examination, laboratory studies, or other diagnostic assessment.
• Guidelines for reducing the use of seclusion and restraint while at the same time maintaining the safety of patients and staff are available in a report developed by APA with the American Psychiatric Nurses Association and the National Association of Psychiatric Health Systems (http://www.psych.org/psych_pract/treatg/pg/learningfromeachother.cfm).

Use diagnostic tests to help establish or exclude a diagnosis, aid in choice of treatment, or monitor treatment effects or side effects.

• Test utility will be determined by the prevalence of the condition in the population, the probability of error (i.e., a false positive or a false negative), and the treatment implications of the test results.
• It is important to have a clear rationale for ordering tests, and each patient must be considered individually.
• Table 3 lists tests that may be indicated in specific clinical situations.

Perform or request a physical examination as needed.

• The patient’s general medical condition may 1) influence or cause psychiatric symptoms, 2) require general medical care, and 3) affect choice of psychiatric treatment.
• When appropriate, the psychiatrist should ensure that indicated medical assessments are done and incorporate these findings into the evaluation.
• The physical examination may be performed by the psychiatrist, another physician, or a medically trained clinician.
• In most circumstances, the physical examination should be chaperoned.

Collaborate with members of multidisciplinary teams who are involved in caring for the patient and making observations about the patient’s behavior and symptoms.

2. The Process of Assessment

Perform an integrative clinical formulation and risk assessment.

• The formulation aids in understanding the patient as a unique human being and appreciating individual strengths and challenges.
• Consider phenomenological, neurobiological, psychological, and sociocultural issues involved in diagnosis and management.
• Consider using the DSM-IV-TR Outline for Cultural Formulation (Table 4) to address sociocultural issues.
• In assessing the patient’s risk of harm to self or others, consider suicide or homicide risk, other forms of self-injury (e.g., cutting behaviors, accidents), aggressive behaviors, neglect of self-care, and neglect of the care of dependents. Identify specific risk factors that may be modifiable by intervention.

Determine a diagnosis.

• Develop a differential diagnosis based on the information obtained in the evaluation and summarized in the integrative clinical formulation.
• Use the DSM multiaxial system of diagnosis as a method for organizing and communicating the patient’s current clinical status.
• To augment the DSM multiaxial approach, consider identifying the patient’s level of defensive functioning or incorporate dimensional approaches into the diagnostic assessment.

Establish a comprehensive initial treatment plan that addresses biopsychosocial domains.

• The plan is ideally the result of collaboration among the patient, the psychiatrist, and other members of the treatment team, including the primary care physician.
• Establish both short- and long-term diagnostic, therapeutic, and rehabilitative goals.
• Consider risks and benefits of potential treatment approaches.
• If resources limit treatment options, consider advocating for the patient to obtain what is needed.

Address legal or administrative concerns as needed (e.g., involuntary admission, duty to protect, level of observation).

Assess family, peer networks, and other support systems.

1. Maintain the patientâ??s privacy and confidentiality.

• In general, maintain confidentiality unless the patient gives consent to a specific communication.
• Under specific clinical circumstances, confidentiality may be attenuated to address the safety of the patient and others.
• According to the Health Insurance Portability and Accountability Act (HIPAA), information from medical records may be released without a specific consent form for purposes of "treatment, payment, and health care operations." Otherwise, patients must sign an authorization form.
• When releasing information to third-party payers (e.g., for utilization review or preauthorization decision), it may be important to request specific rather than blanket consent from the patient.
• Psychotherapy notes have special protection under HIPAA.
• Release of information about individuals evaluated or treated for substance use disorders is governed by the provisions of 42 CFR §2.11

2. Address legal and administrative issues.

• When a patient is admitted to a hospital or other residential setting, clarify legal status and establish whether the admission is voluntary or involuntary.
• Determine if the patient gives or withholds consent to evaluation and treatment.
• Determine if the patient is able to make treatment-related decisions and whether an advance directive (e.g., concerning psychiatric or end-of-life treatment) has been executed.
• If fiscal and administrative issues constrain treatment options, inform the patient, family, and others, including third-party payers, and attempt to find alternatives.

3. Understand and address the needs of patients from special populations.

• Evaluation of elderly patients or patients with medical conditions may emphasize general medical history, cognitive mental status, and level of functioning.
• Evaluation of incarcerated persons may emphasize legal history, previous episodes of incarceration, and alcohol and substance use history. Risk assessment is crucial, because suicide is one of the leading causes of death in correctional settings.
• In overcoming mistrust and fear, engagement of homeless persons over numerous, brief, and seemingly casual interactions in nonclinical settings may precede a formal evaluation.
• Use professionally trained interpreters with mental health experience, when available, for evaluation of patients with limited English proficiency and those who are deaf or have severely limited hearing and who know a sign language.
• Evaluation of persons with mental retardation may emphasize behavioral observations or functional measures, depending on the patient’s ability to understand questions and report on his or her own mental experiences. Co-occurring general medical conditions are often undetected in adults with mental retardation.