PSYCHIATRIC INTERVIEW AUDIT

INTAKE INTERVIEW

  • ED Chart Review
    • ED triage note (note method of presentation, CC, vitals)
    • Visit history (note general reasons, # of admissions, time/context of first diagnosis, longest admission, last admission and ED presentation)
    • Last psychiatric assessment
    • Last discharge summary (utility of hospitalization / interventions, prior pattern of presentations)
    • Netcare current meds
    • Allergies
    • Recent labs
    • Formal status and validity of Form 1
    • Nursing notes (note patient behavior, last vitals)
  • Introduction
    • Your name and role +/- other healthcare professionals in the room
    • +/- Orientation to clinic/program
    • +/- Overview of interview structure
    • Confidentiality and its limits (in intro or integrated in middle of interview)
      • For forensic assessments = inform patient that assessment will not be confidential
    • +/- warning about interrupting patient PRN
    • Limit intro to ~1 minute
    • If telepsychiatry: confirm identity (e.g. DOB) and address of current patient location
  • ID
    • Preferred name
    • Age
    • If entering interview completely blind:
      • If patient is currently admitted to hospital or in outpatient treatment program
      • If admitted: date of hospitalization, certification status, +/- regular bed vs high observation bed
    • Living situation + who they live with
    • +/- Marital status
    • Dependents (children and others)
      • Age of dependents
      • +/- who dependents are living with (if not with patient)
      • If peripartum: GPAL status, EDD (# weeks pregnant) or # weeks postpartum, breastfeeding status
    • Financial status
      • What/when was last job
    • +/- Highest level of education
    • +/- current legal involvement
    • If concerns of capacity (including geriatric): PD/EPOA/will created vs enacted
  • Chief complaint(s)
  • HPI
    • Precipitating factor ie events that brought patient to seek help
      • Timeline of precipitating factors
        • If presenting for chronic presentation: Why now?
      • Cause of stressor (e.g. why break-up, lose job, etc)
      • Method of initial presentation
        • If presented via 911: Who called 911
      • Itemize top 3 stressors
    • Explore domain of chief complaint to arrive at primary diagnosis
      • Timeline of symptoms
        • Focus diagnostic portion of HPI on period of illness before treatment (to not miss disorder in partial remission)
    • Current symptom control compared to before
      • Here and now check-in re presence of symptoms actively in room (mood, anxiety level, psychotic symptoms)
      • Current mood
      • Current sleep
      • Current insight and judgement
        • Patient’s understanding of their current diagnosis
        • If hospitalized: Patient’s desire to remain in hospital
  • Safety
    • Recent SI
      • If present: plan & intent, +/- why they are feeling suicidal, access to modifiable weapons (guns, asphyxiation materials, meds to OD), current SI
        • If recent SI resolved: When was last SI, patient insight on why SI improved
      • Protective factors & future orientation (now or in SHx)
      • Prior history of suicide attempts
        • If present: # of attempts, method, typical trigger
    • Recent SH and prior self-harm attempts
    • Recent HI
      • If paranoid: Measures taken to protect self e.g. carrying weapons on person
      • History of violence
      • Legal history (now or in SHx)
        • Most serious offense
    • +/- driving hazards
    • If cognitive deficits: Fire hazards, wandering risk
  • Substance use
    • Smoking, MJ, alcohol, recreational drugs, IVDU
      • +/- caffeine, energy drinks (especially if c/o anxiety)
      • If unreliable: Ask about specific recreational drugs
    • If positive substance use: Amount, frequency, last used
      • +/- Challenge patient on current income source (ie selling drugs / “involvement in sales and distribution”, prostitution) if initial reported income source is discrepant with cost of drug use
      • If alcohol: History of alcohol withdrawal, seizures, delirium tremens
      • +/- Duration of regular usage, problems caused by drug use ($, work/school, relationships, health)
      • Prior attempts to quit
        • Prior addictions treatment
        • If positive: Longest period of sobriety (especially since onset of symptoms)
          • If > 1 month sobriety: Symptom improvement during sobriety
      • Patient insight into relationship between substances and symptoms
      • Current intent/motivation to quit
        • Benefits and downsides of substance use for patient
  • Psychiatric review of symptoms
    • R/o important diagnostic categories first (e.g. substance-induced > psychosis > bipolar > depression > anxiety)
    • Depression screen (both depressed mood and anhedonia)
      • If positive screen: SIGMECAPS
        • Mood in/congruent psychotic features (e.g. delusions of guilt)
        • Specific cognitive distortions (to assist w/ formulation)
    • Hypo/mania screen (both elevated and irritable types)
      • If positive screen: DIGFAST, mood in/congruent psychotic features
    • Psychosis screen (both delusions and hallucinations)
      • If delusions: False premise of delusions, attempt to challenge fixed nature of delusions
        • If religious delusions: Compare them to what other members of religion think
        • Persecutory delusions, +/- delusions of thought interference, +/- delusions of control / mind reading, +/- referential delusions, +/- grandiose / religious delusions, +/- somatic delusions, +/- jealous / erotomanic delusions
      • If auditory hallucinations: Confirm nature of true AH
        • What voices are saying, command vs non-command
          • If command: If command to hurt self/others
        • +/- Who voice belongs to, # voices, frequency, last
      • If visual hallucinations: +/- detailed nature of VH
    • Anxiety screen
      • If positive:
        • Focus of worry (fear of what will happen)
        • Panic attack screen
          • If panic disorder:
            • +/- Nocturnal panic attacks
            • Screen for agoraphobia and vice versa
        • Screen for comorbid anxiety disorders (currently and leading up to current presentation)
    • OCD screen
    • Trauma & PTSD screen (now or in SHx)
  • Past psychiatric history
    • History of mental health issues
      • If controversial diagnosis: Who diagnosed them (ie if psychiatrist)
    • Prior similar episodes to CC
    • Past psychiatric admissions & for what
    • Current connections to community resources
      • +/- When last seen + next appointment
      • +/- If current counselling: # sessions, frequency, what are they currently working on in counselling, recent example of applying skills used in therapy
    • Past treatments (ie meds, counselling, ECT, etc)
      • Reason for medication discontinuation
        • If claim inefficacy: Was it originally working before “losing efficacy”, highest dose, duration of trial, psychosocial context when became “ineffective”
      • If prior counselling:
        • Type of counselling, duration of counselling
        • What did they learn from counselling
  • Past medical history
    • Pregnancy screen
    • TBI
    • +/- Surgeries
    • If chronic pain: Current pain control nowadays
  • Medications
    • OTC & herbs/supplements
    • Compliance with medications
      • If psychotic / bipolar: If patient is on CTO
    • Concerns with medications
  • Allergies including reaction
  • Family psychiatric history
    • Ask specifically about bipolar and psychosis
    • +/- Ask specifically about depression and anxiety
    • If suspect ADHD: Ask specifically about FHx ADHD, cardiac disease, sudden death
    • If recent SI: Ask specifically about suicide attempts
    • If suspect dementiat: Ask specifically about dementia and neurological diseases
      • If FHx dementia: Type, age of onset
  • Social history
    • Migration history: Where patient was born
      • If originally not born in current city: Overview of migration history, how long patient has been living in current city
        • If frequent moves: Impact on patient
        • If refugee: Reason for fleeing, experience as refugee (eg at refugee camps), current impact, current refugee status
    • Neurodevelopmental history: Complications in utero/pregnancy, developmental delays
      • If history of SUD in mom = history of substance use during pregnancy
    • Childhood history:
      • How was childhood
      • What was mom/dad like, what were their worst qualities, relationship with parents
      • History of abuse (even if other trauma history endorsed)
        • If present: How did it affect patient
    • School history:
      • How was school
      • +/- ADHD screen
      • History of bullying (even if other trauma history endorsed)
      • If < Grade 12 education: Reason for dropping out of school
    • Work history: Overview of employment history, longest job, pattern of reason for job ending, satisfaction with current work
      • If recent SI: Future orientation
    • Legal history
    • Sexual relationship history:
      • Overview of past significant relationships, longest relationship, how did they end
      • +/- sexual identify/orientation
    • Misc relationship history:
      • Current social support and its strength (ie level of involvement in supporting mental health)
        • Other significant relationships (good or bad)
        • Quality of current major relationships (eg spouse, children)
        • If weak social supports: Why patient thinks that is
      • If peripartum: Planned vs unplanned pregnancy, how actual peripartum experience compared to expectations
    • Personality screen (premorbid and currently)
    • Cultural identity (ethnicity, religion/spiritual, sexual, etc)
    • Psychosocial formulation for any experiences that parallel precipitating factor / current presentation (e.g. themes of loss, mistrust)
      • How patient normally responds to stress historically
    • +/- Typical day
  • Terminating interview
    • +/- instill hope

MISC

  • Process
    • Demonstration of here and now (e.g. comment on MSE)
    • Develop discrepancy if present (not immediately at start of interview)
    • Develop rapport with the patient
      • Validating statements / demonstration of empathy
        • Both negative and positive statements
        • Taking time to pause
        • Demonstrate non-verbal and verbal displays of empathy
      • Watch out for verbal habits (e.g. “ok”, “right”, etc)
        • Make sure responses congruent with patient affect
      • +/- check in with patient mid-way
    • Organization
      • Sign-posting
      • +/- summarizing statements
    • Demonstrating control of the interview (especially towards later half of interview)
      • Redirecting / containing the circumstantial patient
      • Demonstrate ability to escalate and de-escalate patient at will
    • Asking open ended questions
    • Simplifying questions
      • Avoiding jargon
    • Avoiding stacked questions
    • Making efforts to clarify vague answers (e.g. give me an answer)
  • Case presentation
    • +/- Acknowledge difficulties of interview / missing information
  • Provisional diagnosis
    • My preferred diagnosis is [commit to actual diagnosis]; may also discuss diagnostic debate
    • Does the DDx match with MSE?
    • You are allowed to discuss diagnostic debate if stuck betw 2 diagnosis pro-actively
  • Formulation
    • Synthesize themes
    • Find parallels between predisposing, precipitating, and perpetuating factors if present
    • Incorporate quotes
    • CBT formulation = ID core belief
  • Management plan
    • Preface that you’ll be organizing your management plan with the safety/biopsychosocial framework
      • Organize treatment into acute, subacute, vs chronic considerations
    • Admit vs not admit
    • Formal status
    • Passes/privileges
    • Safety planning, CFS involvement
    • ID missing information on history
    • Collateral, chart review
      • Contact MDs (other psychiatrists, GP) already involved in care
      • Offer family meeting
    • Rating scales, physical exam
    • Investigations
    • Biological treatments
      • Removing offending substances/medications and treating offending medical conditions
      • Medication adjustments as indicated
      • PRNs (agitation, sleep, nicotine, pain, EPS)
    • Psychosocial treatments
      • Psychoeducation
      • +/- specific psychotherapy modalities
    • Ultimate disposition
  • Q&A period usually about provisional diagnosis, MSE, other content

SAMPLE DOCUMENTATION FORMAT OF PROCESS NOTES

  • Team (clinic/program, case manager, outreach worker, etc)
  • Profile
    1. ID
      • Preferred name, ***age, ***sex, level of functioning (employment status, housing status, marital status)
        • +/- rural residence
        • +/- other main supports, guardian
        • +/- other conversational items
        • +/- poorly engaged
        • +/- active stressors
        • +/- active legal charges
    2. Past Psych Hx
      • Main diagnoses, onset of primary diagnosis
      • Any relevant formulation info for psychotherapy
      • Admissions
        • “Multiple” vs “countless” vs [specific number] since what period of time, longest admission
        • Context / symptoms of prior admissions
          • “When unwell” vs “symptomatic periods involve” vs “relapses typically feature”, “typically triggered by”
            • Prior suicide attempts, self-harm attempts, or violence
            • Peak substance use
          • “At baseline, normally”
        • Last admission, last discharge diagnosis and discharge meds
    3. PMHx
    4. Past Treatments (biological and psychological)
  • [Date] [Intake/Kardex/F/U/Update]
    • Including collateral, on exam, plan
  • ***Provisional diagnosis (numbered from most to least active issue you are treating)
    • Qualifiers to consider using
      • “Well established” > “Query” or “Likely” > “Rule out [disorder]” or “vs” > “Watch for”
      • “Exacerbated by” or “[+/- intermittent] superimposed” or “with underlying”
      • “Historical diagnosis of” or “[disorder], historically diagnosed” > “Remote diagnosis of [disorder], +/- resolved” or “childhood diagnosis of”
      • “Revised from” or “[disorder] ruled out”
      • “Mild” vs “moderate” vs “severe” > “Resolved”, “in [partial vs full] remission”
    • Include diagnostic tasks remaining (eg collateral pending from, etc.)
  • Treatment Targets / Goals
  • ***Current Medications
  • Bloodwork Due
  • CTO / Certification Status
  • Medication Coverage
  • Allergies
  • Current psychosocial treatments
    • Therapist
    • Community connections
    • Skills acquired/reinforced
      • Bibliotherapy provided
      • Safety planning completed
      • Relapse prevention completed
    • Areas of growth
  • ***Recommendations/plan
  • Dispo