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write the medical history portion of the psychiatric report.
After watching the Patient Interview , write the medical history portion of the psychiatric report. The medical history should include the following sections:

· Identification

· Chief Complaint

· History of present illness

· Past psychiatric and medical history

· Family history

· Personal history

· Summation of observations and impressions

· Review of Systems

An example is outlined on page 24 of Kaplan & Sadock’s Synopsis of Psychiatry textbook.

Grading Rubric as follow:

Psychiatric Report: History of Present Illness

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomeChief complaint and History of Present Illness

30 pts

Proficient

Identifies the chief complaint as stated by the patient. Provides at least 4 details in the history of the present illness narrative that clearly relate to the chief complaint.

22.5 pts

Acceptable

Identifies the chief complaint as stated by the patient. Provides at least 3 details in the history of the present illness narrative that clearly relate to the chief complaint.

15 pts

Needs Improvement

Does not identify the chief complaint as stated by the patient. Provides at least 2 details in the history of the present illness narrative. Vague information that may not relate to the chief complaint.

7.5 pts

Unsatisfactory

Does not provide the chief complaint as stated by the patient. Provides 1 detail in the history of the present illness narrative. Vague information that may not relate to the chief complaint.

0 pts

Missing

Does not provide the chief complaint as stated by the patient. Does not provide details in the history of the present illness.

30 pts

This criterion is linked to a Learning Outcome Demographic data and Past Psychiatric History

15 pts

Proficient

Provides at least 6 details in the demographic data and past psychiatric history. Includes a minimum of 1 element for each section.

11.25 pts

Acceptable

Provides at least 4 details in the demographic data and past psychiatric history. Most sections are addressed.

7.5 pts

Needs Improvement

Provides at least 2 details in the demographic data and past psychiatric history. Some sections are addressed.

3.75 pts

Unsatisfactory

Provides at least 1 detail in the demographic data and past psychiatric history. Most sections are not addressed.

0 pts

Missing

Does not discuss demographic data and past psychiatric history.

15 pts

This criterion is linked to a Learning Outcome Past Medical History

15 pts

Proficient

Provides at least 4 details in the past medical history. Includes a minimum of 1 element for each section.

11.25 pts

Acceptable

Provides at least 3 details in the past medical history. Most sections are addressed.

7.5 pts

Needs Improvement

Provides at least 2 details in the past medical history. Some sections are addressed.

3.75 pts

Unsatisfactory

Provides at least 1 detail in the past medical history. Most sections are not addressed.

0 pts

Missing

No past medical history provided

15 pts

This criterion is linked to a Learning Outcome Psychosocial History and Family Psychiatric History

15 pts

Proficient

Provides at least 5 details in the psychosocial and family psychiatric history. Includes a minimum of 1 element for each section.

11.25 pts

Acceptable

Provides at least 3 details in the psychosocial and family psychiatric history. Most sections are addressed.

7.5 pts

Needs Improvement

Provides at least 2 details in the psychosocial and family psychiatric history. Some sections are addressed.

3.75 pts

Unsatisfactory

Provides at least 1 detail in the psychosocial and family psychiatric history. Most sections are not addressed.

0 pts

Missing

No psychosocial and family psychiatric history provided

15 pts

This criterion is linked to a Learning Outcome Review of Systems

15 pts

Proficient

Provides at least 6 details in the review of systems. Includes a minimum of 1 element for each section.

11.25 pts

Acceptable

Provides at least 4 details in the review of systems. Most sections are addressed.

7.5 pts

Needs Improvement

Provides at least 2 details in the review of systems. Some sections are addressed.

3.75 pts

Unsatisfactory

Provides at least 1 detail in the review of systems. Most sections are not addressed.

0 pts

Missing

No review of systems provided.

15 pts

This criterion is linked to a Learning Outcome Organization

5 pts

Proficient

All data and information are placed in the correct section of the note. The note is well organized and clear.

3.75 pts

Acceptable

Minor mistakes in placement of information and data. The note is mostly organized and clear.

2.5 pts

Needs Improvement

Several mistakes in placement of information and data that impact the organization and clarity of the note.

1.25 pts

Unsatisfactory

Numerous mistakes in placement of information. The note is not well organized and is difficult to understand.

0 pts

Missing

Information unreadable, multiple mistakes in organization of data, information is unclear.

5 pts

This criterion is linked to a Learning Outcome Terminology

5 pts

Proficient

Appropriate use of medical terminology. No grammar/ spelling mistakes.

3.75 pts

Acceptable

Minor mistakes with terminology, spelling or grammar.

2.5 pts

Needs Improvement

Several mistakes with terminology, spelling or grammar.

1.25 pts

Unsatisfactory

Frequent mistakes with terminology, spelling or grammar that impact the reader’s ability to understand the note.

0 pts

Missing

Information is unreadable, multiple mistakes, and the information is unclear.

5 pts

Total Points: 100

An example is outlined on page 24 of Kaplan & Sadock’s Synopsis of Psychiatry textbook.

I. Psychiatric History

A. Identification: Name, age, marital status, sex, occupation, language if other than English, race, nationality, and religion if pertinent; previous admissions to a hospital for the same or a different condition; with whom the patient lives

B. Chief complaint: Exactly why the patient came to the psychiatrist, preferably in the patient’s own words; if that information does not come from the patient, note who supplied it

C. History of present illness: Chronologic background and development of the symptoms or behavioral changes that culminated in the patient’s seeking assistance; patient’s life circumstances at the time of onset; personality when well; how illness has affected life activities and personal relations—changes in personality, interests, mood, attitudes toward others, dress, habits, level of tenseness, irritability, activity, attention, concentration, memory, speech; psychophysiological symptoms—nature and details of dysfunction; pain—location, intensity, fluctuation; level of anxiety—generalized and nonspecific (free floating) or specifically related to particular situations, activities, or objects; how anxieties are handled—avoidance, repetition of feared situation, use of drugs or other activities for alleviation

D. Past psychiatric and medical history: (1) Emotional or mental disturbances—extent of incapacity, type of treatment, names of hospitals, length of illness, effect of treatment; (2) psychosomatic disorders: hay fever, arthritis, colitis, rheumatoid arthritis, recurrent colds, skin conditions; (3) medical conditions: follow customary review of systems—sexually transmitted diseases, alcohol or other substance abuse, at risk for acquired immunodeficiency syndrome (AIDS); (4) neurologic disorders: headache, craniocerebral trauma, loss of consciousness, seizures, or tumors

E. Family history: Elicited from patient and from someone else, because quite different descriptions may be given of the same persons and events; ethnic, national, and religious traditions; other persons in the home, descriptions of them—personality and intelligence—and what has become of them since patient’s childhood; descriptions of different households lived in; present relationships between patient and those who were in family; role of illness in the family; family history of mental illness; where does patient live—neighborhood and particular residence of the patient; is home crowded; privacy of family members from each other and from other families; sources of family income and difficulties in obtaining it; public assistance (if any) and attitude about it; will patient lose job or apartment by remaining in the hospital; who is caring for children

F. Personal history (anamnesis): History of the patient’s life from infancy to the present to the extent it can be recalled; gaps in history as spontaneously related by the patient; emotions associated with different life periods (painful, stressful, conflictual) or with phases of life cycle

1. Early childhood (Birth through age 3)

a. Prenatal history and mother’s pregnancy and delivery: Length of pregnancy, spontaneity and normality of delivery, birth trauma, whether patient was planned and wanted, birth defects

b. Feeding habits: Breast-fed or bottle-fed, eating problems

c. Early development: Maternal deprivation, language development, motor development, signs of unmet needs, sleep pattern, object constancy, stranger anxiety, separation anxiety

d. Toilet training: Age, attitude of parents, feelings about it

e. Symptoms of behavior problems: Thumb sucking, temper tantrums, tics, head bumping, rocking, night terrors, fears, bed-wetting or bed soiling, nail biting, masturbation

f. Personality and temperament as a child: Shy, restless, overactive, withdrawn, studious, outgoing, timid, athletic, friendly patterns of play, reactions to siblings

2. Middle childhood (ages 3–11): Early school history—feelings about going to school, early adjustment, sex identification, conscience development, punishment; social relationships, attitudes toward siblings and playmates

3. Later childhood (prepuberty through adolescence)

a. Peer relationships: Number and closeness of friends, leader or follower, social popularity, participation in group or gang activities, idealized figures; patterns of aggression, passivity, anxiety, antisocial behavior

b. School history: How far the patient went, adjustment to school, relationships with teachers—teacher’s pet or rebellious—favorite studies or interests, particular abilities or assets, extracurricular activities, sports, hobbies, relationships of problems or symptoms to any school period

c. Cognitive and motor development: Learning to read and other intellectual and motor skills, minimal cerebral dysfunction, learning disabilities—their management and effects on the child

d. Particular adolescent emotional or physical problems: Nightmares, phobias, masturbation, bed-wetting, running away, delinquency, smoking, drug or alcohol use, weight problems, feeling of inferiority

e. Psychosexual history

i. Early curiosity, infantile masturbation, sex play

ii. Acquiring of sexual knowledge, attitude of parents toward sex, sexual abuse

iii. Onset of puberty, feelings about it, kind of preparation, feelings about menstruation, development of secondary sexual characteristics

iv. Adolescent sexual activity: Crushes, parties, dating, petting, masturbation, wet dreams and attitudes toward them

v. Attitudes toward same and opposite sex: Timid, shy, aggressive, need to impress, seductive, sexual conquests, anxiety

vi. Sexual practices: Sexual problems, homosexual and heterosexual experiences, paraphilias, promiscuity

f. Religious background: Strict, liberal, mixed (possible conflicts), relation of background to current religious practices

4. Adulthood

a. Occupational history: Choice of occupation, training, ambitions, conflicts; relations with authority, peers, and subordinates; number of jobs and duration; changes in job status; current job and feelings about it

b. Social activity: Whether patient has friends or not; is patient withdrawn or socializing well; social, intellectual, and physical interests; relationships with same sex and opposite sex; depth, duration, and quality of human relations

c. Adult sexuality

i. Premarital sexual relationships, age of first coitus, sexual orientation

ii. Marital history: Common-law marriages, legal marriages, description of courtship and role played by each partner, age at marriage, family planning and contraception, names and ages of children, attitudes toward raising children, problems of any family members, housing difficulties if important to the marriage, sexual adjustment, extramarital affairs, areas of agreement and disagreement, management of money, role of in-laws

iii. Sexual symptoms: Anorgasmia, impotence, premature ejaculation, lack of desire

iv. Attitudes toward pregnancy and having children; contraceptive practices and feelings about them

v. Sexual practices: Paraphilias such as sadism, fetishes, voyeurism; attitude toward fellation, cunnilingus; coital techniques, frequency

d. Military history: General adjustment, combat, injuries, referral to psychiatrists, type of discharge, veteran status

e. Value systems: Whether children are seen as a burden or a joy; whether work is seen as a necessary evil, an avoidable chore, or an opportunity; current attitude about religion; belief in heaven and hell

G. Summation of the examiner’s observations and impressions derived from the initial interview

II. Mental Status

A. Appearance

1. Personal identification: May include a brief nontechnical description of the patient’s appearance and behavior as a novelist might write it; attitude toward examiner can be described here—cooperative, attentive, interested, frank, seductive, defensive, hostile, playful, ingratiating, evasive, guarded

2. Behavior and psychomotor activity: Gait, mannerisms, tics, gestures, twitches, stereotypes, picking, touching examiner, echopraxia, clumsy, agile, limp, rigid, retarded, hyperactive, agitated, combative, waxy

3. General description: Posture, bearing, clothes, grooming, hair, nails; healthy, sickly, angry, frightened, apathetic, perplexed, contemptuous, ill at ease, poised, old looking, young looking, effeminate, masculine; signs of anxiety—moist hands, perspiring forehead, restlessness, tense posture, strained voice, wide eyes; shifts in level of anxiety during interview or with particular topic

B. Speech: Rapid, slow, pressured, hesitant, emotional, monotonous, loud, whispered, slurred, mumbled, stuttering, echolalia, intensity, pitch, ease, spontaneity, productivity, manner, reaction time, vocabulary, prosody

C. Mood and affect

1. Mood (a pervasive and sustained emotion that colors the person’s perception of the world): How does patient say he or she feels; depth, intensity, duration, and fluctuations of mood—depressed, despairing, irritable, anxious, terrified, angry, expansive, euphoric, empty, guilty, awed, futile, self-contemptuous, anhedonic, alexithymic

2. Affect (the outward expression of the patient’s inner experiences): How examiner evaluates patient’s affects—broad, restricted, blunted or flat, shallow, amount and range of expression; difficulty in initiating, sustaining, or terminating an emotional response; is the emotional expression appropriate to the thought content, culture, and setting of the examination; give examples if emotional expression is not appropriate

D. Thinking and perception

1. Form of thinking

a. Productivity: Overabundance of ideas, paucity of ideas, flight of ideas, rapid thinking, slow thinking, hesitant thinking; does patient speak spontaneously or only when questions are asked, stream of thought, quotations from patient

b. Continuity of thought: Whether patient’s replies really answer questions and are goal directed, relevant, or irrelevant; loose associations; lack of causal relations in patient’s explanations; illogic, tangential, circumstantial, rambling, evasive, perseverative statements, blocking or distractibility

c. Language impairments: Impairments that reflect disordered mentation, such as incoherent or incomprehensible speech (word salad), clang associations, neologisms

2. Content of thinking

a. Preoccupations: About the illness, environmental problems; obsessions, compulsions, phobias; obsessions or plans about suicide, homicide; hypochondriacal symptoms, specific antisocial urges or impulses

3. Thought disturbances

a. Delusions: Content of any delusional system, its organization, the patient’s convictions as to its validity, how it affects his or her life: persecutory delusions—isolated or associated with pervasive suspiciousness; mood congruent or mood incongruent

b. Ideas of reference and ideas of influence: How ideas began, their content, and the meaning the patient attributes to them

4. Perceptual disturbances

a. Hallucinations and illusions: Whether patient hears voices or sees visions; content, sensory system involvement, circumstances of the occurrence; hypnagogic or hypnopompic hallucinations; thought broadcasting

b. Depersonalization and derealization: Extreme feelings of detachment from self or from the environment

5. Dreams and fantasies

a. Dreams: Prominent ones, if patient will tell them; nightmares

b. Fantasies: Recurrent, favorite, or unshakable daydreams

E. Sensorium

1. Alertness: Awareness of environment, attention span, clouding of consciousness, fluctuations in levels of awareness, somnolence, stupor, lethargy, fugue state, coma

2. Orientation

a. Time: Whether patient identifies the day correctly; or approximate date, time of day; if in a hospital, knows how long he or she has been there; behaves as though oriented to the present

b. Place: Whether patient knows where he or she is

c. Person: Whether patient knows who the examiner is and the roles or names of the persons with whom in contact

Summary of Findings

Summarize mental symptoms, medical and laboratory findings, and psychological and neurologic test results, if available; include medications patient has been taking, dosage, duration. Clarity of thinking is reflected in clarity of writing. When summarizing the mental status (e.g., the phrase “Patient denies hallucinations and delusions” is not as precise as “Patient denies hearing voices or thinking that he is being followed.”). The latter indicates the specific question asked and the specific response given. Similarly, in the conclusion of the report one would write “Hallucinations and delusions were not elicited.”