A psychiatric evaluation is both a clinical assessment and a legal document. It establishes the clinical baseline, informs the diagnostic impression, and drives the treatment plan. Whether you are a psychiatrist, psychiatric nurse practitioner, or clinical psychologist performing a comprehensive evaluation, the documentation must be thorough, organized, and clinically defensible. This guide walks through each component in the order they typically appear in a complete psychiatric evaluation report.
Identifying Information and Reason for Referral
Begin with basic identifying information: the patient's name (or identifier if de-identified), age, gender, date of the evaluation, and who requested the evaluation and why. The reason for referral is distinct from the chief complaint — it is the referring clinician's or agency's stated reason for seeking the evaluation. "Patient referred by PCP for evaluation of new-onset depressive symptoms and assessment for medication management" tells a different story than "patient self-referred due to dissatisfaction with prior psychiatric care."
Chief Complaint
The chief complaint is the patient's own words explaining why they have sought help. Always use quotation marks. "I've been feeling like nothing matters anymore and I can't get out of bed" is more clinically alive than "patient presents with depressive symptoms." The chief complaint anchors the evaluation in the patient's subjective experience and reminds subsequent readers that there is a person behind the clinical data.
History of Present Illness
The HPI is the heart of the psychiatric evaluation. It narrates the current episode of illness with clinical precision: When did symptoms begin? Was the onset acute or gradual? What were the earliest symptoms? How have symptoms evolved over time? What is their current severity and functional impact? What makes them better or worse? Have there been prior episodes of similar symptoms? What treatment, if any, has been sought for this episode, and what was the response?
A well-written HPI is a story, not a checklist. It follows a chronological arc and builds toward the clinical picture the evaluator has observed. Use the OLDCARTS mnemonic (Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, Severity) as a structural guide, but write the HPI in coherent prose, not bullet points.
Psychiatric History
Document all prior psychiatric diagnoses, noting your clinical confidence in each. Prior hospitalizations deserve specific documentation: facility, dates, length of stay, reason for admission, and treatment received. Outpatient treatment history should include prior therapists and prescribers, treatment modalities, and duration of engagement. Prior medication trials are particularly important: document each medication, the dose reached, the duration of the trial, the response, and the reason for discontinuation. This history prevents repeating failed treatments and builds on successful ones.
Medical History
Document significant medical conditions, noting any with known psychiatric implications. Hypothyroidism can cause or exacerbate depression. Sleep apnea causes cognitive impairment and mood disturbance. Autoimmune conditions are associated with psychiatric comorbidities. Traumatic brain injury affects mood, cognition, and behavior. A thorough medical history also identifies potential contraindications for psychiatric medications and conditions that require coordination with other providers.
Family Psychiatric History
Ask about psychiatric conditions, substance use disorders, and suicide in first- and second-degree relatives. Be specific: a family history of "depression" is less useful than knowing that the patient's mother had recurrent major depression that responded well to sertraline, and the patient's grandfather died by suicide at age 54. Genetic loading for psychiatric conditions is a meaningful risk factor, and family medication response histories are clinically useful when choosing treatments.
Social History
The social history covers the patient's developmental, educational, occupational, and relational history. Developmental milestones, early attachment experiences, and childhood adversity all provide context for adult functioning. Educational history (highest level achieved, any learning disabilities, academic performance) gives insight into cognitive functioning and early adjustment. Occupational history reveals patterns of success and difficulty. Current and past relationships — including any history of domestic violence — are important for understanding interpersonal functioning and risk. Legal history, including current legal stressors, is relevant to clinical management.
Substance Use History
Document current and historical use of all substances: alcohol, cannabis, stimulants, opioids, benzodiazepines, hallucinogens, and others. For each substance, document age of first use, frequency of use, quantity, periods of heaviest use, any tolerance or withdrawal symptoms, and any prior treatment for substance use. Substance use affects diagnosis (many substances cause or mimic psychiatric symptoms), treatment (some medications are contraindicated with certain substances), and prognosis. Use non-stigmatizing language.
Mental Status Examination
The MSE is the objective clinical observation of the patient's mental functioning at the time of the evaluation. It should be documented in its own section with systematic coverage of all domains: appearance, behavior, speech, mood, affect, thought process, thought content, perceptions, cognition, insight, and judgment. (See the dedicated MSE documentation article for detailed guidance on each domain.) The MSE provides a clinical snapshot that anchors the diagnostic impression in observable findings.
Diagnostic Impression and Differential Diagnosis
The diagnostic impression lists the DSM diagnoses with codes, organized from primary to secondary. More importantly, the narrative diagnostic impression explains your reasoning — how the clinical data supports each diagnosis and how you distinguished among competing diagnostic possibilities. A diagnostic impression without reasoning is just a list of labels; a diagnostic impression with reasoning demonstrates clinical thinking.
Document your differential diagnosis: what other conditions you considered and why you ruled them in or out. "Major depressive disorder is the primary diagnosis; bipolar II was considered given a reported period of increased energy and decreased sleep need approximately two years ago, but the patient and collateral informants describe a period of normal mood rather than elevated mood, arguing against a hypomanic episode" is the kind of reasoning that makes a psychiatric evaluation clinically defensible.
Risk Assessment and Treatment Recommendations
Close the evaluation with a formal risk assessment covering suicidality, homicidality, self-harm, and any other relevant safety concerns, followed by treatment recommendations. Recommendations should flow logically from the clinical findings: specific psychotherapy modalities, medication recommendations with rationale, level of care recommendation (outpatient, intensive outpatient, partial hospitalization, inpatient), referrals, and monitoring plan. The evaluation report is most useful when treatment recommendations are specific enough to actually guide the treating clinicians.