Psychiatric Interview Documentation

Psychiatric Interview Documentation

Preparing the Assignment

Follow these guidelines when completing each component of the assignment. Contact your course faculty if you have questions.

APA

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General Instructions

1. Download the Psychiatric Interview Template.
2. Watch the Psychiatric Interview Recording and complete the required psychiatric interview documentation. Client age and allergies have been completed.

Psychiatric Interview Documentation

Include the following elements:

1. History of present illness (HPI)
   • Include the chief complaint in quotation marks
   • List only HPI data
   • Use appropriate terminology
   • Provide support from an appropriate scholarly source or textbook to support content and terminology
   • Provide information that is understandable, well-organized, and easy to follow
2. Medications
   • Provide all current medication information
   • Include all criteria from the medication table
   • Use appropriate medical terminology
   • Provide information that is understandable, well-organized, and easy to follow
3. Past psychiatric history
   • Include entire past psychiatric history
   • Address all criteria listed on the template
   • Use appropriate terminology
   • Provide support from an appropriate scholarly source or textbook to support content and terminology
   • Provide information that is understandable, well-organized, and easy to follow

4. Medical history

5. Include all relevant medical information
6. Address all criteria listed on the template
7. Use appropriate terminology
8. Provide support from an appropriate scholarly source or textbook to support content and terminology
9. Provide information that is understandable, well-organized, and easy to follow
10. Family History
11. Include all pertinent family history
12. Address all criteria listed on the template
13. Use appropriate terminology
14. Provide support from an appropriate scholarly source or textbook to support content and terminology
15. Provide information that is understandable, well-organized, and easy to follow
16. Social History
17. Include all relevant information from the social history
18. Address all criteria listed on the template
19. Use appropriate terminology
20. Provide support from an appropriate scholarly source or textbook to support content and terminology
21. Provide information that is understandable, well-organized, and easy to follow
22. Review of systems (ROS)
23. Address all ROS criteria listed on the template
24. Use appropriate terminology
25. Provide support from an appropriate scholarly source or textbook to support content and terminology
26. Provide information that is understandable, well-organized, and easy to follow
27. Mental status examination (MSE)
28. Include each element of the MSE
29. Address all criteria listed on the template
30. Use appropriate terminology
31. Provide support from an appropriate scholarly source or textbook to support content and terminology
32. Provide information that is understandable, well-organized, and easy to follow
33. List items not addressed during the interview and discuss whether listed items were appropriately omitted or should be included. Cite a reference to support the listed items.
34. Formatting
35. Carlat’s (2017) textbook is used to support terminology and section content
36. Sources represent a logical link between the source content and the interview documentation
37. In-text citations match listed references
38. Direct quotes are not used

Submit your completed template to the Week 6 Dropbox.

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