30 Minute Psychiatric Diagnostic Interview : This is a template that needs to be

30 Minute Psychiatric Diagnostic Interview
:
This is a template that needs to be adjusted for individuals based on chronological and developmental age, culture, etc. Add questions as you see fit in appropriate areas.
Add rating scales as appropriate (MMSE for older adult or disabled). Review of systems to determine what needs further evaluation, labs, etc. Vital signs?
Patient (age, marital status, gender; ethnicity, reliable?) Review of systems for specific follow up.
Source of Data:
SUBJECTIVE DATA IDEALLY – introduce self – Minute 1
Chief Complaint: LISTEN – Minutes 2-4
History of Present Illness /past psychiatric history/safety– Minutes 5-12:
Present Illness: explore issues in depth-get details of patient’s story and validate patient’s feelings. Do symptom analysis of each area of concern.
Neurovegetative Symptoms:
Sleep: (get full details of duration, etc if problems)
Appetite and weight: (recent)
Psychomotor Agitation or Retardation
Energy:
Anhedonia: What do you enjoy doing?
Concentration:
Guilt/Worthlessness: Mood: Rate mood on 1-10 scale with 10 as best (or 1-100 with 50 being “level or stable mood” if suspect bipolar disorder, and below 50 depressed and above 50 manic)
Diurnal variation of mood:
Anxiety/ OC and related disorders/ PTSD : ( Ask at least 3 key screening questions for each disorder; if yes to any of the screening questions, you will need to assess all the criteria for that disorder to arrive at diagnosis using DSM 5 criteria (not all criteria are listed here); if no’s then no further questions needed re that disorder.
Specific phobia:
(see DSM 5)
GAD: Do you worry a lot? Do you ever feel restless, fidgety, or jittery? Muscle tension, feel the worse thing will happen? Fatigue?
Panic disorder :
Agoraphobia:
Social Anxiety Disorder (Social Phobia:
PTSD:
OC and Related disorders
OCD:
Body Dysmorphic Disorder;
Other: trichotillomania, skin picking, hoarding (see DSM 5)
Manic Symptoms: (Ask at least 5 screening questions to rule out mania; if yes to any, need thorough details of duration of symptoms and severity to determine if meets criteria for hypomania or mania episodes (Bipolar Disorder I or II)
Psychosis: Hallucinations:
Delusions:
Focus and attention: problems with inattention?
Consequences of any of the + symptoms:
Past Psychiatric History:
Report any psychiatric history in reverse chronological order.
Alcohol and Other Drug use History:
Tobacco, alcohol, illicit drugs? (Make sure to ask about each specific drug in this section. This also includes prescription drugs as well (e.g. Soma, Vicodin, Xanax); if HPI includes drugs and alcohol, cover in HPI; can say see HPI.)
Ask about size of drink: use standardized drink chart for size of drink, 12 oz beer, 1 ½ oz liquor, 5 oz wine =`1 drink See the guidelines or asking these questions in Clinicians Guide. More than 14 drinks a week for men, 7 drinks a week for women is considered problem use. CAGE questionnaire (not as useful as AUDIT (or CRAAFT with teen) or questions about # drinks)
Go through each class of drugs (Current, past, first use, last use, consequences) illicit /street drugs
Marijuana, cocaine, methamphetamine, opiates (Vicodin, Lortab, Oxycodone), benzos, hallucinogens, inhalants, ecstasy,? (ask the questions about abuse and dependency, withdrawal and intoxication of any drugs admitted to using)
Abuse OTC such as dextromethorphan / bath salts?
Caffeine/nicotine use
Safety:
Suicidal ideation:
Homicidal ideation: Have you ever thought that things would be better if someone else was dead?
Current Plan? Intent?
Psych Review of systems: Minutes 13-17
Checking for what may not have come out in the history of present illness. If person answers affirmatively, explore further using DSM 5 criteria.
Mood
Psychosis
Anxiety
Trauma
Dissociation
Somatic Concerns
Eating and Feeding
Sleeping
Substances and other Addictions
Personality (patterns causing difficulty)
Elimination
Health Status: Minutes 18-23
Current Health Status
Allergies (drug/other)
Current psychiatric and other prescribed medications: (include dosages and when taking; any missed doses; side effects)
OTC, herbal
Immunization status (if applicable) *Required with Pedi
Health maintenance behaviors
Diet, exercise, self-exams, safety, etc.
Last physical exam (date, PCP) Last dental exam?
LMP; menstrual history
Systems questions
Past Health Status:
Past medical problems? (go through common illnesses: heart disease, diabetes, arthritis, asthma, etc)
Past operations? Accidents? Hospitalizations? Surgeries? (get dates, etc)
Head injuries? Did you lose consciousness
Any past prescription, OTC, herbal medications? What kind? What did you take them for?
For women: Pregnancy history, complications? C-Section? Vaginal delivery?
Family History:
Psychiatric disorder such as depression, ADHD, bipolar, or drug and alcohol abuse?
Find out FH for above in each member (include parents, siblings, grandparents, aunts, uncles, cousins, offspring)
Health problems in family members (cardiac, diabetes, sudden death; etc )
Genogram of family
Suicides in family
Developmental History (learning problems, etc.)
Social History (jobs, religion, military, legal history, support system, etc.)
Mental Status: Minutes 24-28
Mental Status Exam (MSE):
Appearance
Behavior
Speech
Mood
Affect
Thought Process
Thought content
Cognition and intellectual resources
Insight/judgement
Mini-Mental State Examination (MMSE):
Name, date and time, place, immediate recall, attention (counting backwards by 7’s from 100, spelling world backward), delayed recall, general information (president, governor, five cities), abstractions, proverbs, naming, repetition, three-stage command, reading, copying, writing.
Follow-up questions: Minutes 29-30
Is there anything important that I missed or should know about?
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Diagnostic interview rubric (1)
Diagnostic interview rubric (1)
Criteria
Ratings
Pts
This criterion is linked to a Learning Outcome Description of patient and chief complaint
10 to >5.0 pts
Thorough description of patient and chief complaint in patient’s own words
5 to >0.0 pts
Missing important detail or no use of patient’s words
0 pts
Vague description of patient
10 pts
This criterion is linked to a Learning Outcome History of past/present illness
10 to >5.0 pts
Thorough history of symptoms, timeline, treatment, and medications of past/present illness
5 to >0.0 pts
Missing one piece of information from past/present history without explanation
0 pts
Inadequate
10 pts
This criterion is linked to a Learning Outcome Family/developmental/social history
10 to >0.0 pts
Full Marks
0 pts
No Marks
10 pts
This criterion is linked to a Learning Outcome Mental status
10 to >0.0 pts
Full Marks
0 pts
No Marks
10 pts
This criterion is linked to a Learning Outcome Psychiatric review of systems
10 to >0.0 pts
Full Marks
0 pts
No Marks
10 pts
This criterion is linked to a Learning Outcome Health status
10 to >0.0 pts
Full Marks
0 pts
No Marks
10 pts
This criterion is linked to a Learning Outcome Follow up questions/other info needed
10 to >0.0 pts
Full Marks
0 pts
No Marks
10 pts
This criterion is linked to a Learning Outcome Neurobiology, developmental neuroscience, or interpersonal neurobiology
10 to >0.0 pts
Full Marks
0 pts
No Marks
10 pts
This criterion is linked to a Learning Outcome Uses appropriate evidence/criteria to support diagnosis and differential diagnoses
10 to >5.0 pts
Identifies diagnosis and considers all appropriate (relevant) differential diagnoses
5 pts
Missing more than one diagnosis that should be considered
5 to >0.0 pts
Missing one diagnosis that should be considered
0 pts
Inadequate
10 pts
This criterion is linked to a Learning Outcome Uses APA format, with correct spelling/grammar/punctuation and proper citations
10 to >5.0 pts
100% correct
5 to >0.0 pts
1-3 errors (with repeated errors counting as individual errors)
0 pts
4-6 errors
10 pts
Total Points: 100