Initial Psychiatric Evaluation


Initial Psychiatric Evaluation

Initial Psychiatric Evaluation

Initial Psychiatric Evaluation 03/13/2019 12:43 PM


Awaiting review

Start and End Time

Start time

03/13/2019 12:43 PM

End time

I. Identifying Information

Admit Date/Time:

March 08, 2019 at 12:00 AM MST

Admission Type:



Marital Status:


Allergies/Drug Reactions:

AllergenAllergy TypeReactionReaction TypeOnsetTreatmentStatus TypeSource
AbilifyDrugRash/HivesAdverse Reaction “Stop taking it”Active 


Current Medications

☑ No medication

II. Chief Complaint

Heroin and Meth abuse

III. History of Present Illness:  (Include a history of present illness, including onset, precipitating factors and reason for the current admission, signs and symptoms, course, and the results of any treatment received.)

23yo WM with long history of substance abuse presenting for treatment again. He has been in various treatment programs over the past several years, has done prison time. He relapsed in sober living while on Suboxone after the dose was decreased from 12mg to 6mg and has gone back into more structured programming to stabilize again. He says he gets overwhelmed with life circumstances that start piling up that he has a thought of using and then can’t stop himself. When in treatment, his focus is directed and he is able to handle stressors one at a time.


IV. Past Psychiatric & Substance Treatment History: (Including prior precipitating factors, diagnosis, course and treatment) (Has the patient been chronically ill? Continuously/repeatedly? How severely has the past illness/treatment interfered with the patient’s development and/or adjustment? Are there persistent symptoms/signs/behaviors that must be addressed and treated in order to favorably impact on the future psychiatric course? What medications or supports helped him/her improve in the past? Are the same resources available to impact on the patient’s treatment during this episode)

Been in rehab many times, longest period of sobriety has been 7 months, drug of choice is heroin, has used IV in past and last time was 2015. He started using Marijuana at age 10, first rehab at age 13. Seen psych as a child and been on many different medications, unable to remember all of them but says they seemed to either make him tired and fall asleep during the day or upset his stomach. Has tried abilify recently but had a rash. As a child he remembered Strattera, Ritalin, Wellbutrin, Risperdal, Zoloft, Seroquel.

V. Pertinent Past Psychiatric History: (check all that apply)

• Failure of outpatient/IOP treatment

• H/O violence to self, others, property

• H/O recurrent problems with psycho-active substances

• H/O legal problems

VI. Background & Social History:  (Include family, educational, vocational,occupational and social history)

Grew up with parents who divorced when he was 13 and he split time, completed through 8th grade, currently working as a carpenter for past 10 months, single and no kids

VII. Medical/Surgical History:

HSV, tonsils removed

VIII. Seizure History:


IX. Head/Trauma History:


X. Trauma/Abuse History:

has been raped in the past, sexually abused as child

XI. Psychosocial/Development/Family History Overview:

Alcohol abuse

XII. Previous History Suicidal/Homicidal Ideation/Plan:


XIII. Current Suicidal/Homicidal Ideation/Plan:


XIV. Mental Status Exam: (Check all Symptoms Present)

A. Appearance:

Well Groomed , Relaxed , Age appropriate , Appropriate

B. Speech

Fluent Speech

C. Behavior:

Calm , Good Eye Contact

D. Attitude:

Cooperative , Tense

E. Mood:

Anxious , Irritable

F. Affect:

Intense , Anxious

G. Self and/or Others Agressive/Destructive Thoughts and Behaviors:

Suicidal Ideation


Homicidal Ideation


Self Destructive Behaviors


H. Thought Process:


I. Thought Content:

• Denies

J. Vegetative Signs:

XV. Cognitive Assessment:

A. Orientation:

B. Last Five Presidents: Able to Recall:

C. Learn Three Objects (e.g. 3 feathers, 11 envelopes, 29th Avenue)

D. Digit Span (e.g. 9 6 4 6 1 7)

Number forward Correctly

Number backward Correctly

E. Repeat Three Objects (See “C”)

F. Intelligence Estimate:


G. Memory:

1. Immediate Recall


2. Short Term


3. Long Term


4. Concentration


5. Attention


H. Impulse Control:


I. Introspection:


K. Judgement:


XVI. Strengths & Assets: (check all that apply)

• Cooperative

• Capacity to perform ADL/s

XVII. Liabilities/Barriers to Recovery:

XVIII. Diagnostic Impressions/Diagnosis:

DSM V Diagnosis


F11.20 Opioid use disorder, Severe,F32.9 Unspecified depressive disorder,r/oPTSD


Medical Conditions:


Psychosocial Stressors:

• Problems related to social environment

• Problems related to interaction with legal system / crime

• Problems with sexual abuse / trauma

Need for Suicide Precautions:




XIX. The patient has been fully informed by the psychiatrist about the possible risks and probable benefits of their treatment. The patient has expressed to the psychiatrist an understanding of the explanations that were provided by the psychiatrist.


XX. Justification for Detox, Intensive Inpatient, Residential Treatment or PHP Treatment:

• Acute history of psychoactive substance abuse

• Acute history inability to maintain any type of long-term absence from psychoactive substances

XXI. Treatment Recommendations:

• PHP/Day-Night

• Medication Management

• Individual Psychotherapy

• Group Psychotherapy

• Psychoeducational Groups

• Aftercare Plan

XXII. Psychopharmacologic Interventions:

Taper off Subutex – tonight 1mg and tomorrow night 1mg then stop  Add Robaxin 500mg 1-2 tabs tid prn pain, max 6 tabs per day  Add Vistaril 50mg qid prn anxiety  Consider initiating antidepressant next week after completed taper, will discuss further

Risks, benefits, side effects, and dosage schedule explained to patient:


Client verbalized understanding of teaching:



next week

On this examination, the patient demonstrated signs suggestive of Tardive Dyskinesia. The potential risks and long term consequences of this disorder, and treatment alternatives, were discussed and understood by the patient/guardian.


XXIII. Physician Certification of Need for Admission: As a physician duly licensed to practice medicine, I hereby certify that treatment is medically necessary. I certify that treatment could not be effectively provided at a lesser intensive level of care and that the patient is able to participate in all aspects of the treatment program. All treatment services will be provided to the patient under my direction and under a written plan of care. Having completed this Physician Initial Certification of Need for Admission, I do authorize and order the patient’s admission.

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