5
Recommended Aspects of the Initial Psychiatric Evaluation
Examination, Including Mental Status Examination
• General appearance and nutritional status
• Height, weight, and body mass index (BMI)
• Vital signs
• Skin, including any stigmata of trauma, self-injury, or drug use
• Coordination and gait
• Involuntary movements or abnormalities of motor tone
• Sight and hearing
• Speech, including fluency and articulation
• Mood, degree of hopelessness, and level of anxiety
• Thought content, process, and perceptions, including current hallucinations,
delusions, negative symptoms, and insight
• Cognition
• Current suicidal ideas, suicide plans, and suicide intent, including active or
passive thoughts of suicide or death
▶ If current suicidal ideas are present, assess: patient's intended course of
action if current symptoms worsen; access to suicide methods including
firearms; patient's possible motivations for suicide (e.g., attention or
reaction from others, revenge, shame, humiliation, delusional guilt,
command hallucinations); reasons for living (e.g., sense of responsibility
to children or others, religious beliefs); and quality and strength of the
therapeutic alliance.
• Current aggressive ideas, including thoughts of physical or sexual aggression
or homicide
▶ If current aggressive ideas are present, assess: specific individuals or
groups toward whom patient's homicidal or aggressive ideas or behaviors
have been directed in the past or at present; impulsivity, including anger
management issues and access to firearms
Adapted from APA's Practice Guidelines for the Psychiatric Evaluation of Adults, 3rd Edition.
Arlington VA, American Psychiatric Association, 2016. Copyright © 2016 American Psychiatric
Association. Used with permission.
(cont'd)
