Psychiatric Diagnosis and DSM 5 Diagnostic Criteria

History of Present Psychiatric Illness

(Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient Mental Health Services)

General Appearance

Presenting Appearance (nutritional status, physical deformities, hearing impaired, glasses, injuries, cane)
Basic Grooming and Hygiene (clean, disheveled and whether it is appropriate attire for the weather)

Gait and Motor Coordination (awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest),
posture (slouched, erect),
any noticeable mannerisms or gestures

Level of Participation in the Program/Activity (Group attendance and milieu participation, exercise)

Manner and Approach

Interpersonal Characteristics and Approach to Evaluation (oppositional/resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness)

Behavioral Approach (distant, indifferent, unconcerned, evasive, negative, irritable, depressive, anxious, sullen, angry, assaultive, exhibitionistic, seductive, frightened, alert, agitated, lethargic, needed minor/considerable reinforcement and soothing).
Coping and stress tolerance.

Speech (normal rate and volume, pressured, slow, loud, quiet, impoverished)

Expressive Language (no problems expressing self, circumstantial and tangential responses, difficulties finding words, echolalia, mumbling)

Receptive Language (normal, able to comprehend questions,

Orientation, Alertness, and Thought Process

Recall and Memory (recalls recent and past events in their personal history).
Recalls three words (e.g., Cadillac, zebra, and purple)
Orientation (person, place, time, presidents, your name)

Alertness (sleepy, alert, dull and uninterested, highly distractible)
Coherence (responses were coherent and easy to understand, simplistic and concrete, lacking in necessary detail, overly detailed and difficult to follow)

Concentration and Attention (naming the days of the week or months of the year in reverse order, spelling the word “world”, their own last name, or the ABC's backwards)

Thought Processes (loose associations, confabulations, flight of ideas, ideas of reference, illogical thinking, grandiosity, magical thinking, obsessions, perseveration, delusions, reports of experiences of depersonalization).
Values and belief system

Hallucinations and Delusions (presence, absence, denied visual but admitted olfactory and auditory, denied but showed signs of them during testing, denied except for times associated with the use of substances, denied while taking medications)

Judgment and Insight (based on explanations of what they did, what happened, and if they expected the outcome, good, poor, fair, strong)

Mood and Affect

Mood or how they feel most days (happy, sad, despondent, melancholic, euphoric, elevated, depressed, irritable, anxious, angry).
Affect or how they felt at a given moment (comments can include range of emotions such as broad, restricted, blunted, flat, inappropriate, labile, consistent with the content of the conversation.

Rapport (easy to establish, initially difficult but easier over time, difficult to establish, tenuous, easily upset)
Facial and Emotional Expressions (relaxed, tense, smiled, laughed, became insulting, yelled, happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicious, tearful, pessimistic, optimistic)

Response to Failure on Test Items (unaware, frustrated, anxious, obsessed, unaffected)
Impulsivity (poor, effected by substance use)
Anxiety (note level of anxiety, any behaviors that indicated anxiety, ways they handled it)

Lab

Range

Value

Reason Obtained

Risk Assessment:

Suicidal and Homicidal Ideation

(ideation but no plan or intent, clear/unclear plan but no intent) Self-Injurious Behavior (cutting, burning) Hypersexual, Elopement, Non-adherence to treatment

Discharge Plans and Instruction: Placement, outpatient treatment, partial hospitalization, sober living, board and care, shelter, long term care facility, 12 step program

Teaching Assessment and Client / Family Education:

(Disease process, medication, coping, relaxation, diet, exercise, hygiene) Include barriers to learning and preferred learning styles