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Psychiatric Interview Template: Mental Health Assessment Guide, Assignments of Nursing

Chamberlain College of NursingNursing

A psychiatric interview template used to gather information about a patient's mental health history, current symptoms, and overall well-being. It includes sections for chief complaint, history of present illness, past psychiatric history, medical history, family history, social history, and review of systems. The template also includes a mental status exam section to assess the patient's appearance, behavior, speech, affect, thought process, attention, memory, orientation, insight, and judgment. A structured approach to collecting and documenting relevant information for psychiatric evaluation and treatment planning. It is a valuable tool for mental health professionals in assessing and managing patients with psychiatric conditions. The template also includes a section for references to evidence-based peer-reviewed journal articles related to the case.

Typology: Assignments

2024/2025

Available from 06/14/2025

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Psychiatric Interview Template
Initials: K.S Age: 54 Gender: male
Include vital signs if provided . Document not provided if not available.
Height Weight Allergies (and reaction)
5’9 150 Medication: none
Food: shellfish-
anaphylaxis
Environment: none
History of Present Illness (HPI)
Chief Complaint (CC) “I’m here to be seen by another provider due to VA having a shortage of
providers”
CC is a BRIEF statement identifying
why the client is here - in the patient’s
own words - for instance "I have been
feeling depressed," NOT "symptoms of
depression for 3 weeks.” History of
Present Illness (HPI)
(1) Develops illness narrative (cogent
story with clear chronology, not a
list of symptoms), and
(2) includes specific details of
symptoms, and the impact of these
symptoms on daily life.
HPI
K.S is a 54 year old male that presents to clinic for continuation of treatment for depression and
bipolar. Has been seeing providers at the VA every 3 months but due to recent shortage he has
permission to seek outside providers for treatment. Has been diagnosed with depression for about
20 years with current treatment of Wellbutrin and lithium. Reports mood has been stable since
starting new treatment of Wellbutrin 6 months ago. Appetite good. Sleeps well. Reports need for
medication refill in the upcoming weeks due to changing providers.
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication
(Rx, OTC, or Homeopathic) Dosage Frequency Length of Time
Used Reason for Use
lithium 900mg Every bedtime 15 years Mood instability/bipolar
Wellbutrin XL 300mg Every morning 6 months depression
Synthroid unknown Every morning Click or tap here
to enter text.
hypothyroidism
Click or tap here to enter text. Click or tap here to
enter text.
Click or tap here to enter
text.
Click or tap here
to enter text.
Click or tap here to enter text.
Click or tap here to enter text. Click or tap here to
enter text.
Click or tap here to enter
text.
Click or tap here
to enter text.
Click or tap here to enter text.
Name: Shandrisha Lawson
S: Subjective
(Information the client or representative told you)
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Partial preview of the text

Download Psychiatric Interview Template: Mental Health Assessment Guide and more Assignments Nursing in PDF only on Docsity!

Psychiatric Interview Template

Initials: K.S Age: 54 Gender: male Include vital signs if provided. Document not provided if not available. Height Weight Allergies (and reaction) 5’9 150 Medication: none Food: shellfish- anaphylaxis Environment: none History of Present Illness (HPI) Chief Complaint (CC) “I’m here to be seen by another provider due to VA having a shortage of providers” CC is a BRIEF statement identifying why the client is here - in the patient’s own words - for instance "I have been feeling depressed," NOT "symptoms of depression for 3 weeks.” History of Present Illness (HPI) (1) Develops illness narrative ( cogent story with clear chronology, not a list of symptoms), and (2) includes specific details of symptoms, and the impact of these symptoms on daily life.

HPI

K.S is a 54 year old male that presents to clinic for continuation of treatment for depression and bipolar. Has been seeing providers at the VA every 3 months but due to recent shortage he has permission to seek outside providers for treatment. Has been diagnosed with depression for about 20 years with current treatment of Wellbutrin and lithium. Reports mood has been stable since starting new treatment of Wellbutrin 6 months ago. Appetite good. Sleeps well. Reports need for medication refill in the upcoming weeks due to changing providers. Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Medication (Rx, OTC, or Homeopathic) Dosage^ Frequency^ Length of Time Used Reason for Use lithium 900mg Every bedtime 15 years Mood instability/bipolar Wellbutrin XL 300mg Every morning 6 months depression Synthroid unknown Every morning Click or tap here to enter text. hypothyroidism Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Name: Shandrisha Lawson

S: Subjective

(Information the client or representative told you)

Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details. Include all provided information. If not assessed leave blank or select “other” if not applicable to the client. Constitutional If patient denies all symptoms for this system, check here: ☐ Skin If patient denies all symptoms for this system, check here: ☒

HEENT

If patient denies all symptoms for this system, check here: ☒ ☐Fatigue Click or tap here to enter text. ☐Weakness Click or tap here to enter text. ☐Fever/Chills Click or tap here to enter text. ☐Weight Gain Click or tap here to enter text. ☐Weight Loss Click or tap here to enter text. ☒Trouble Sleeping hx of trouble sleeping but since Wellbutrin tx, he is sleeping much better ☐Night Sweats Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Rashes Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Diplopia Click or tap here to enter text. ☐Vision changes Click or tap here to enter text. ☐Photophobia Click or tap here to enter text. ☐Earache Click or tap here to enter text. ☐Tinnitus Click or tap here to enter text. ☐Epistaxis Click or tap here to enter text. ☐Vertigo Click or tap here to enter text. ☐Hearing Changes Click or tap here to enter text. ☐Other: Click or tap here to enter text. Respiratory If patient denies all symptoms for this system, check here: ☒ Neuro If patient denies all symptoms for this system, check here: ☒ Cardiac If patient denies all symptoms for this system, check here: ☒

MSK

If patient denies all symptoms for this system, check here: ☒ Name: Shandrisha Lawson

☐Pain on Inspiration Click or tap here to enter text. ☐Snoring : Click or tap here to enter text. ☐Other: Click or tap here to enter text. enter text. ☐Sensation Changes Choose an item. ☐Speech Deficits Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Other: Click or tap here to enter text. Hematology/Lymphatics If patient denies all symptoms for this system, check here: ☒

GI

If patient denies all symptoms for this system, check here: ☒

GU

If patient denies all symptoms for this system, check here: ☒ Endocrine If patient denies all symptoms for this system, check here: ☐ ☐Anemia Click or tap here to enter text. ☐ Other Click or tap here to enter text. ☐Nausea/Vomiting Click or tap here to enter text. ☐Dysphasia Click or tap here to enter text. ☐Diarrhea Click or tap here to enter text. ☐Appetite Change Click or tap here to enter text. ☐Heartburn Click or tap here to enter text. ☐Abdominal Pain Click or tap here to enter text. Click or tap here to enter text. ☒Other: Click or tap here to enter text. ☐Urgency Click or tap here to enter text. ☐Polyuria Click or tap here to enter text. ☐Nocturia Click or tap here to enter text. ☐Incontinence Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐ Increased appetite Click or tap here to enter text. ☐ Increased thirst Click or tap here to enter text. ☒ Thyroid disorder hypothyroidism ☐ Heat/cold intolerance Click or tap here to enter text. ☐ Excessive sweating Click or tap here to enter text. ☐ Diabetes Click or tap here to enter text. ☐ Other Click or tap here to enter text. Name: Shandrisha Lawson

O: Objective

Document pertinent positive and negative assessment findings. Pertinent positive are the “abnormal” findings and pertinent “negative”

are the expected normal findings. Separate the assessment findings accordingly and be detailed. Use appropriate terminology.

Downloaded by study. guider ([email protected])

Mental status exam Findings Appearance Choose an item. (^) Congruent with age, well groomed, and appropriate dress Behavior Choose an item. (^) Cooperative and polite. Slightly fidgety Speech Choose an item. (^) Speech was monotonous and slow with increased latency at the start of each sentence. Replies were brief and required prompting. Affect

Choose an item. His affect^ was^ restricted^ and^ flat,^ with^ minimal^ variation^ in^ facial^ expression^ or^ tone^ of^ voice.

Thought Process Choose an item.

His thoughts seemed coherent and linear.

Thought Content Choose an item. Appropriate with no psychosis, hallucinations, or suicidal/homicidal ideations. Attention and Concentration Choose an item. Adequate to engage in conversation. Easy to engage with moderate eye contact. Memory Choose an item. (^) Intact for recent and remote memory. Orientation Choose an item. (^) Alert and oriented to person, place, and time, and situation Insight Choose an item. (^) Good insight. Judgement Choose an item. (^) Good judgement Name: Shandrisha Lawson