Psychiatry history taking

I. Establishing rapport A. The first step in interviewing a psychiatric patient is to establish rapport and create an environment where the patient feels comfortable disclosing personal information. The examiner should begin by introducing himself and stating the purpose of the interview. B. The examiner should be caring, competent, and concerned about helping. Good listening will often provide the patient with confidence in the examiner and facilitate trust and openness. II. Interview structure A. The structure of the clinical interview does not usually follow a rigid format. It is best to guide the patient through their psychiatric history by listening to specific cues the patient provides and responding with appropriate questions and comments. B. History taking typically begins with open- ended questions, which allow the patient to tell the story in his own words. Directed, or more close-ended questions, are used later to elicit specific details when the examiner requires further elaboration. III. Observation A. How the patient speaks and behaves is equally important as what they say. Assessment begins with simple observation of the patient. Personality characteristics and the way in which patients view themselves and interact with their environment are also considered with the presenting complaint. B. The emphasis of the clinical interview is to establish a working diagnosis based on Diagnostic Criteria (DSM-IV-TR) and to develop an appropriate treatment plan. Much of the interview is focused on asking specific questions designed to reveal the presence of symptoms consistent with mood, psychotic, and anxiety disorders. IV. Mental status exam A. The mental status exam is an assessment that provides a common language to describe patient characteristics. The interview provides data that help to elucidate elements of the patient’s presenting complaints and history. The mental status of the patient may change with each exam, and results are relevant only to the time of the interview. B. When discussing an impression of a patient, it is useful to begin by summarizing the mental status exam. V. Written format A. The psychiatric report presents the history in a specific written format. The report includes a proposed multiaxial diagnosis and summarizes the clinical impression and management recommendations. B. Suggestions for further work-up are also included, such as laboratory testing, neurological examinations, diagnostic testing, and gathering information from family, friends, and other health-care providers.