A comprehensive psychiatric evaluation is a detailed assessment of an individual’s mental health history, current symptoms, and overall functioning. It is typically conducted by a psychiatric professional, such as a psychiatrist, psychologist, or social worker. The evaluation may include a review of the patient’s medical and psychiatric history, a physical examination, and the use of various assessment tools, such as questionnaires or standardized tests. The goal of the evaluation is to gather enough information to accurately diagnose any mental health conditions the patient may have and develop a treatment plan.
A comprehensive psychiatric evaluation note is a document that summarizes the findings of the evaluation. It may include details about the patient’s presenting symptoms, any relevant medical or psychiatric history, the results of any assessment tools used, and the psychiatric professional’s diagnosis and recommendations for treatment.
Here is an example of a patient case:
Patient: Jane Doe
Age: 32
Presenting complaint: Jane has been experiencing symptoms of depression for the past six months, including low mood, lack of energy, difficulty concentrating, and changes in appetite and sleep. She has also been experiencing anxiety and has had several panic attacks.
Medical history: Jane has a history of asthma and has been treated with inhalers and other medications for this condition. She has no other significant medical history.
Psychiatric history: Jane has a history of depression and has been treated with antidepressants in the past. She has also received counseling for her depression.
Assessment: During the evaluation, Jane reported experiencing symptoms of depression and anxiety as described above. She also reported feeling overwhelmed and stressed due to her job as a teacher, as well as financial and relationship problems. She scored high on a depression assessment tool and moderate on an anxiety assessment tool.
Diagnosis: Based on the evaluation, the psychiatric professional diagnosed Jane with major depressive disorder and generalized anxiety disorder.
Recommendations: The psychiatric professional recommended a combination of medication and counseling for the treatment of Jane’s depression and anxiety. They also recommended that Jane consider making lifestyle changes to reduce stress, such as exercising regularly and finding ways to manage her financial and relationship problems.
