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6 Cards in this Set
- Front
- Back
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Introduction
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a. Introduce yourself
b. State what you are c. Say who sent you d. Say why you are there e. Give a time frame Example: "Hello, Ms./Mr./Mrs. ____, I'm a medical student, working with Dr. ____. He/she asked me to come in and get some basic information about what brought you here. I have about forty-five minutes to talk now, but I can come back later and talk if we need more time." |
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11 steps of psychiatric interview
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1. Introduction
2. Chief Complaint 3. History of Present Illness 4. Developmental/Social History 5. Past Medical History 6. Family History 7. Review of Systems 8. Mental Status Exam 9. Formulation 10. Diagnoses 11. Treatment plan |
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7 content items of psych HPI
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Location: "where" is the problem in the patient's life
Quality: What is the problem like? Severity: How bad is the problem? Timing: When does it occur? Is there a particular time of day or situation when the problem is better or worse? Context: What sort of situations will bring the problem on? Modifying factors: Is there anything that makes it better or worse? Has the patient tried anything to help? Associated features: Is there anything else associated with the problem. |
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Elements of Developmental/Social History:
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a. Social context: This includes many factors, such as marriage, family, occupation, living situation, and environmental stressors.
b. Development: Developmental issues such as history of traumatic events, childhood neglect, and other traumas are important. c. Education d. Military service |
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elements of mental status exam
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a. Appearance
b. Behavior c. Speech d. Mood e. Affect: f. Thought process g. Thought content h. Cognition i. Insight j. Judgement |
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axes of psych diagnosis
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a. Axis I: Major mental illness diagnoses (e.g., major depression, panic disorder, etc.)
b. Axis II: Personality and developmental disorder diagnoses c. Axis III: Physical illnesses d. Axis IV: Stressors e. Axis V: Estimation of the current level of functioning |
