ELEMENTS OF A PSYCHIATRIC HISTORY

Element Description

Identifying Data Summarizes the case, including information about previous hospitalizations
or treatment and some indication of the current problem

e.g. this is one of the numerous psychiatric admissions for this 45-year-old
woman, who is readmitted at this time for the recurrence of paranoia,
auditory hallucinations, and suicidal ideation

Chief Complaint Describe the client’s perception of the current problem

e.g. “The voices are telling me to kill myself and I can’t get away from
them.”

Present Illness History Describes events leading to admission for seeking of Psychiatric help.

e.g. The client was discharged from the hospital 1 month ago. She attended
day treatment but took her medication inconsistently. Over the past 3 days,
she had become preoccupied with suicide. She states she has recently
discovered that her husband is having an affair, and she thinks she wants to
leave her. She blames herself for the difficulties in her marriage.

Past Medical History Outlines medical conditions including laboratory or diagnostic data.

e.g. There are no known medical conditions.

Developmental and Outlines circumstances that are significant for understanding the current
Psychosocial History problems. Includes such information or school history, relationships with
family members, and developmental stage.

e.g. Client is the middle child in the family of three children. her parents
had an intact marriage, although there was a great deal of hostility between
them. She has flashbacks of her mother and father yelling at each other in
the night. She has completed college with a liberal arts degree. She is
employed part-time in a local decorating business.

Mental Status Exam Evaluates the client’s mental and emotional functioning, including
appearance, behavior, and attitude; characteristics of speech; affect and
mood; thought content (delusions, illusions, ability to concentrate);
orientation, memory; intellectual level; and suicidal ideations.

e.g. The client is cooperative with the interviewer. Her mood and affect are
depressed and anxious. He became tearful throughout the interview. Her
flow of thought content reveals feelings if low self-esteem as well as
auditory hallucinations that are demeaning. She admits to suicidal ideas but
denies having a plan or intent. Her orientation is good. She knows the
current date, place and person. Recent and remote memory is good. She
shows some insight and judgment regarding her illness and need for help.

Critical Decisions Assesses the client’s immediate status and risk factors.

e.g.
Is the client suicidal?
Is there a potential for suicide in the near future?
Is the client violent?