Psychiatric History & Physical Assessment Tools

When taking a psychiatric and physical history, there is no formal right and wrong. Most clinicians have their own methods based on opinion, patient history and personal preferences for gathering information. During the first session with a mental health patient, clinicians listen to the content of the history, but they also observe the way the patient interacts and behaves. However, there are formal evaluations available to practitioners who feel more comfortable using standardized means to evaluate their patients.

Structured Interviews

• The Diagnostic and Statistical Manual of Mental Health Disorders (DSM-IV-TR) published by the American Psychiatric Society contains guidelines for diagnosis of psychopathology and is widely used by psychologists and psychiatrists. Psychologists and psychiatrists have worked in conjunction with the DSM in order to create a series of structured clinical interviews that allow doctors to take an accurate and focused history. The interviews can be general or geared toward a specific disorder such as affective or personality disorders. The information gathered then can be used to create a formal DSM diagnosis.

Mini Mental Status Exam

• The Mini Mental Status Exam is a short form that allows for clinicians to quickly and easily evaluate cognitive concerns in the context of a psychiatric interview. Though it has many forms, one of the most popular was developed by psychologists Marshal and Susan Folstein in the mid-1970s; the test has 11 questions that yield a maximum score of 30 points. The test covers the subject's orientation, memory, visual and spatial skills and general cognitive awareness. This is often used in conjunction with standard physical exams, especially where there is a suspicion of compromised mental health.

Formal Psychiatric Testing

• When psychiatric testing is needed to help establish a patient's history and diagnosis, there are many choices available to the clinician. Large formal psychological tests include the Minnesota Multiphasic Personality Inventory, which is a true/false questionnaire with 567 questions that asks the subject about his beliefs and daily behaviors. The responses then generate clinical and validity scales to help the clinician determine a diagnosis and emotional status. There do exist shorter inventories such as the Beck Depression Inventory and the Children's Depression Inventory. The use of formal psychological testing during a psychiatric evaluation is left to the discretion of the clinician.

Evaluations

• Psychiatric and physical evaluations are complex. Clinicians choose tools to gather information based on the referral question, case history and patient stability, both cognitively and emotionally. Remember that training and education are required to conduct a psychiatric and physical evaluation. These tools are not meant to scored or interpreted by unlicensed individuals.