Let?s talk now about the components of the psychiatric history and assessment.
When taking a history from a patient, forming a therapeutic alliance is going to lay
the foundation for your work with that patient. So making an alliance is extremely important.
Here are a few tips to help you build that strong bond with your patient.
First, don?t forget to introduce yourself. Allow the patient to feel comfortable
by creating a room in an atmosphere that?s inviting and welcoming for them.
Also, invite your patient to share a narrative or a story. Avoid asking yes and no questions
but rather open the floor to them and be nonjudgmental as they tell you what?s on their mind.
Always follow your patient?s lead. They may go off on tangents but it?s important to follow
their train of thought. This helps them feel comfortable and it lets them feel as if they can trust you.
Also, in that very first encounter, remember to respect the patient?s wishes to avoid certain subjects.
You can always come back to it later. And finally, staff safety is just as important as patient safety.
Therefore, before initiating an encounter with any patient, make sure that the room is staged
in a way that people feel comfortable and also exits are easily accessible for the patient and staff alike.
Taking a patient?s history involves several components that are all very important.
For example, begin with open-ended questions and then you can always narrow down
your approach based off of that patient?s chief complaint. Explore the present illness with the patient.
Ask them about their symptoms, what precipitated this event, what kind of social setting they?re in
and what kind of supports they have. Be curious about their current and past treatment options
and complications that they?ve had. Also, collect thorough information.
This is a psychiatric assessment but it?s extremely important that not only do you ask
about psychiatric history, you also inquire about medical and surgical history.
Ask about substance abuse history, family history, medications that the patient is taking,
their allergies and safety, including not only their present safety but past suicidal
and homicidal thoughts, consider their social history and their developmental history.
Finally, when taking the mental status exam, this is a critical component of the psychiatric assessment.
It?s basically equivalent to what you do in medicine when you do a physical exam.
The mental status exam includes your observations, direct questions to the patient
about their thoughts, beliefs, perceptions and cognition and it also creates a picture of the patient.
So, consider the mental status exam as something that you can use as a tool to describe them
to peers, colleagues and other members of the treatment team.
They should be able to formulate a picture of the patient without having ever met them solely
based off of your descriptions from their mental status exam. When you formulate a patient,
there are a couple of things to consider. First of all, depending on your setting,
you may be referring to diagnostic criteria according to an ICD-10 or a DSM-5 coding system.
Also, it?s important to take a biopsychosocial approach to the patient
when you?re formulating their illness and also their treatment and their future trajectory.
The biopsychosocial approach includes things like considering biological, psychological
and social predisposing, precipitating and perpetuating factors that are interfering
with one?s ability to achieve the best of mental health.