Introduction
A Comprehensive Psychiatric Evaluation Note is a detailed clinical document used by mental health professionals to assess, diagnose, and plan treatment for individuals experiencing psychological distress or psychiatric symptoms. Unlike focused notes, comprehensive evaluations provide a full picture of the patient’s mental health status, history, and functioning. These notes are essential for initial assessments, treatment planning, and continuity of care.
Purpose of a Comprehensive Psychiatric Evaluation
Establish a psychiatric diagnosis
Identify contributing factors (biological, psychological, social)
Assess risk (suicidality, self-harm, violence)
Develop a personalized treatment plan
Facilitate communication among healthcare providers
Key Components of the Evaluation Note
1. Identifying Information
Name, age, gender, date of birth
Date of evaluation
Referral source (self, family, physician, court)
2. Chief Complaint
Patient’s own words describing the reason for seeking help
Example: “I’ve been feeling hopeless and can’t sleep for weeks.”
3. History of Present Illness (HPI)
Onset, duration, and progression of symptoms
Triggers or stressors
Impact on daily functioning
Previous episodes and treatments
4. Past Psychiatric History
Previous diagnoses
Hospitalizations
Medications and therapy
Suicide attempts or self-harm
Substance use history
5. Medical History
Chronic illnesses (e.g., diabetes, hypertension)
Neurological conditions
Medications and allergies
Surgical history
6. Family Psychiatric History
Mental health conditions in immediate or extended family
Genetic predispositions
7. Social History
Living situation
Education and employment
Relationships and support systems
Legal issues
Cultural and spiritual background
8. Substance Use History
Alcohol, tobacco, illicit drugs
Frequency, quantity, duration
Impact on mental and physical health
Mental Status Examination (MSE)
The MSE is a structured assessment of the patient’s current mental functioning.
Domain Description
Appearance Grooming, hygiene, clothing
Behavior Eye contact, psychomotor activity
Mood Subjective emotional state
Affect Observable emotional expression
Speech Rate, volume, coherence
Thought Process Logical, tangential, disorganized
Thought Content Delusions, obsessions, suicidal ideation
Perception Hallucinations
Cognition Orientation, memory, attention
Insight Awareness of illness
Judgment Decision-making ability
Risk Assessment
Suicidal ideation or intent
Homicidal ideation
Self-injurious behavior
Abuse or neglect
Access to means (e.g., weapons, medications)
Diagnostic Impression
Based on DSM-5 criteria, the clinician provides a working diagnosis. This may include:
Primary psychiatric diagnosis (e.g., Major Depressive Disorder)
Secondary diagnoses (e.g., Substance Use Disorder)
Rule-outs or provisional diagnoses
Formulation
A biopsychosocial summary explaining how biological, psychological, and social factors contribute to the patient’s condition.
Example: “Patient’s depressive symptoms are likely influenced by genetic predisposition, recent job loss, and lack of social support.”
Treatment Plan
Pharmacological
Initiation or adjustment of medications
Monitoring for side effects and efficacy
Psychotherapy
CBT, DBT, psychodynamic therapy, family therapy
Referrals
Psychiatry, psychology, social work, substance abuse programs
Safety Planning
Crisis hotline numbers
Removal of harmful objects
Emergency contacts
Follow-Up
Frequency of visits
Goals for next session
Documentation Tips
Use clear, objective language
Avoid jargon when possible
Include direct quotes from the patient
Ensure confidentiality and compliance with HIPAA
Conclusion
A Comprehensive Psychiatric Evaluation Note is a foundational tool in mental health care. It allows clinicians to gather essential information, make accurate diagnoses, and create effective treatment plans. For students and professionals, mastering this format is key to delivering high-quality psychiatric care.