Psychiatrist Initial Assessment Clinical Notes Template

Psychiatric Initial Assessment Clinical Notes

Referral Information and Presenting Complaint

• Summary of Referral Reasons:

The patient, referred as “Jane,” was referred for a psychiatric evaluation due to concerns about worsening mood instability, feelings of hopelessness, and social withdrawal. The referral was made by Jane’s primary care physician after she reported increasing difficulty managing stress and emotions, leading to disruptions in both her personal and professional life.

• List of Symptoms as Reported by the Patient:

Jane reports feeling “overwhelmed” by daily tasks and has had increasing difficulty coping with work-related pressures. She mentions frequent episodes of sadness, irritability, and a sense of emotional numbness. Jane describes difficulty falling asleep, frequent feelings of exhaustion, and a lack of interest in activities she once enjoyed. There is also a history of tearfulness, especially in the evenings. She reports low self-esteem, guilt about her inability to meet expectations, and occasional thoughts of “wanting to escape it all.” There are no clear suicidal thoughts or plans at this time.

Social Context

• Detailed Account of the Patient’s Social History:

Jane is a 34-year-old woman who is currently married and has two young children, aged 5 and 7. She works full-time as a marketing manager for a mid-sized tech company but has been on a reduced schedule due to feeling overwhelmed. Jane describes her relationship with her spouse as “strained,” particularly in the past year, due to her work stress and emotional exhaustion. She reports a supportive relationship with her mother, but limited engagement with her father. Jane has few close friends and has become more withdrawn socially. Hobbies once enjoyed, such as hiking and painting, have been neglected in favor of more sedentary activities. Jane’s social network is described as “small but reliable,” although she expresses difficulty asking for help.

History of Presenting Complaint

• Description of the Complaint:

Jane reports that her mood has been increasingly unstable over the past year, particularly following a promotion at work, which brought added responsibilities and expectations. She notes that her symptoms began gradually with stress about work deadlines and family responsibilities. Recently, she has felt “trapped” by her daily routine and is unsure how to regain control over her life. There has been no significant trauma or loss noted, though she mentions a sense of isolation and a perceived lack of control over her emotional state.

Current Psychiatric History and Discussion

• Detailed Timeline of Symptoms, Onset, and Progression:

Jane first experienced symptoms of mood instability approximately 12 months ago, following a promotion at work. She initially attributed these feelings to job stress but soon realized the symptoms were persisting despite professional support. Over time, Jane noticed a steady decline in her emotional regulation, including frequent tearfulness, feelings of inadequacy, and irritability. The duration and intensity of symptoms have escalated, with Jane reporting a consistent inability to “snap out of it” despite efforts to engage in self-care and maintain her usual activities.

• Factors Affecting Symptoms:

• Aggravating: Work-related stress, balancing family demands, and feelings of guilt regarding her inability to manage these responsibilities.

• Easing: Time spent alone, engaging in passive activities like watching TV or browsing social media, though these have not provided long-term relief.

• Significant Life Events: Promotion at work, increased responsibilities, and ongoing family obligations have been the primary stressors.

• Current Substance Use/Misuse and Its Impacts:

Jane reports minimal use of alcohol, typically consuming one or two glasses of wine per week. She denies use of illicit substances and reports no significant impact of alcohol consumption on her mood or functioning.

• Screening for Symptoms of Psychosis, Mood Disorders (Depression/Mania), Anxiety Disorders, and Personality Disorders:

Jane denies any history of psychosis or manic episodes. Her mood symptoms appear consistent with depression, and she screens positive for several markers of major depressive disorder, including sleep disturbances, feelings of worthlessness, and diminished interest in previously enjoyed activities. Anxiety symptoms are not as prominent, although Jane experiences occasional racing thoughts about her work and family. There is no history of personality disorders, and Jane does not meet criteria for any pervasive personality disturbance at this time.

• Assessment of Risk Behaviors and Immediate Risks:

Jane reports passive thoughts of death, without any intent or plan for suicide. She denies self-harming behavior and expresses a desire to manage her symptoms. At this time, there are no immediate concerns for acute safety risks, though regular monitoring of her emotional state and any emerging suicidal ideation is warranted.

Past Psychiatric History

• Chronological Account of Past Psychiatric Illnesses, Hospitalizations, and Treatment Responses:

Jane has no prior psychiatric diagnoses, hospitalizations, or treatments. She has sought brief counseling in the past for relationship difficulties but did not engage in long-term therapy.

• Documentation of Compliance and Non-Engagement in Previous Treatments:

Jane’s past counseling experiences were short-lived, and she did not follow through with further appointments, stating that “things got better on their own.” She reports limited success with self-help strategies and is now seeking more structured support.

Past Medical History

• Chronic Medical/Surgical Conditions:

Jane has a history of asthma, well-controlled with an albuterol inhaler as needed. She reports no major surgeries or chronic conditions such as hypertension or diabetes.

Current Medications and Allergies

• Medications:

Jane is not currently taking any psychiatric medications but uses an albuterol inhaler as needed for asthma. She is otherwise not on any prescription medications.

• Allergies:

No known drug allergies.

Family Background and Dynamics

• Immediate Family Members:

• Mother: A 58-year-old woman, retired, who has had a close relationship with Jane throughout her life.

• Father: A 60-year-old man who is estranged from Jane, with limited communication.

• Spouse: A 36-year-old man employed full-time in finance, described as “supportive” but somewhat distant due to Jane’s emotional withdrawal.

• Children: Two children, aged 5 and 7, who live with Jane and her husband. Jane describes her relationship with her children as “loving but strained,” as she struggles with her emotional regulation and parenting responsibilities.

• Family History of Psychiatric Conditions:

Jane’s mother has a history of anxiety, which has been managed with therapy. No known family history of mood disorders or other significant psychiatric conditions.

Social and Developmental History

• Developmental Milestones:

Jane’s developmental milestones were reported as typical, with no delays in speech, motor skills, or social development. She graduated from high school and completed a bachelor’s degree in marketing.

• Current Social Circumstances and Support Systems:

Jane reports having a small social circle with few close friends. Her support system consists mainly of her mother, although they do not engage in frequent conversations about Jane’s mental health struggles. Jane’s spouse is a secondary support, but their relationship has been strained due to her mood instability.

Substance Misuse History

• Detailed History of Substance Use:

Jane reports minimal alcohol use, typically only socially. She denies use of any illicit substances or prescription medication misuse.

Forensic and Legal Issues

• Summary of Outstanding Legal Issues:

No legal issues or history of criminal activity reported.

Mental State Examination (MSE)

• Appearance and Behavior:

Jane is a well-groomed woman appearing her stated age. She was alert and oriented to person, place, and time. Her behavior was cooperative, but she demonstrated signs of distress when discussing emotional concerns.

• Mood and Affect:

Mood: Depressed, with a sense of hopelessness and frustration.

Affect: Restricted, with limited range observed.

• Speech (tone, volume, flow, form):

Normal rate and volume, although speech was sometimes slow when discussing distressing topics.

• Thought Content:

No delusions or hallucinations. Jane denies any active suicidal ideation but reports passive thoughts of death. No homicidal ideation.

• Perception:

No perceptual disturbances noted. Jane denies auditory or visual hallucinations.

• Cognition:

Cognition intact, with no evidence of confusion or disorientation. Short-term and long-term memory appeared intact.

• Insight and Capacity:

Insight: Fair, with an understanding of her current emotional struggles.

Capacity: Full capacity to understand treatment options and make decisions about care.

Formulation and Diagnosis

• Summary of the Case:

Jane’s symptoms are consistent with a diagnosis of major depressive disorder, likely triggered by a combination of work stress and family obligations. The depressive symptoms have significantly impacted her functioning and well-being. There is no current evidence of psychosis, mania, or other mood disorders at this time.

• Provisional Diagnosis:

• Major Depressive Disorder, Moderate, Recurrent (F33.1)

• Rule out Generalized Anxiety Disorder (F41.1)

Risk Assessment

• Risks to Self and Others:

No immediate risk of harm to self or others. Jane’s passive suicidal thoughts will be monitored closely.

• Health Risks:

Jane’s physical health appears stable, with well-managed asthma. No significant health risks identified.

• Other Identified Risks:

Potential risks associated with emotional instability affecting her social and professional life.

Recommended Management/Treatment Plan

• Setting for Treatment:

Outpatient therapy is recommended.

• Prescribed Medications:

Antidepressant medications, specifically an SSRI, will be considered based on further assessment. A trial of psychotherapy (CBT or IPT) is recommended.

• Required Investigations:

Routine blood tests to rule out any underlying medical conditions affecting mood. No immediate ECG or imaging needed at this time.

• Psychosocial Interventions:

Cognitive-behavioral therapy (CBT) to address negative thought patterns and improve coping skills. Consideration of family therapy if relationship strain persists.

• Patient Education and Advice:

Discussed lifestyle factors, including the importance of sleep hygiene, regular physical activity, and stress management techniques.

• Follow-Up Appointments:

Jane is scheduled for a follow-up appointment in two weeks to assess her response to initial interventions.

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