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When performing an assessment and delivering treatment to a patient with mental illness, the psychiatric interview is considered one of the most critical elements (Sadock et al., 2014). The psych assessment or interview, according to research, is a vital component that helps the provider to establish a thorough plan to diagnose/treat and build a successful treatment plan (Carlat, 2017). The use of cognitive interviewing can be helpful when exploring a client’s self-report of symptoms, or issues (Norris et al., 2014). For this week’s assignment I will discuss the initial interview format that I use when interviewing a client, elaborating on how my current preceptor conducts her initial interviews, and describe the elements that are most helpful.

The Interview format that I would use for an initial interview of the client

  • Demographic information: Name, age, gender, marital status, residence and religion
  • Chief complaint
  • History of presenting complaints: Patient’s presenting symptoms, associations, and Treatments     received in the past.
  • Past medical history: Current illnesses, past significant illnesses, allergies to food and drugs.
  • Past Psychiatric history. History of mental disorders in the past
  • Personal and social history: Developmental history, social history including interpersonal relationships, hobbies, childhood traumas or abuse.
  • Family history: Presence of psychiatric disorders in the family.
  • Substance and Drug abuse history
  • Forensic History: Criminal records of the patient in the past.
  • Review of systems: Identifies illnesses or disorders in other systems.
  • General and physical examination
  • Mental status examination (MSE). Explores Appearance and behavior of the patient, mood and affect, speech, cognition, judgment, thoughts, perception, memory and insight.
  • Diagnostic formulation: Differential diagnosis
  • Management plan: Investigations and specific treatment

Describe the format my preceptor utilizes for an initial interview

      My preceptor uses the patient-centered interview technique focusing on key areas to make a diagnosis. The initial interview often lasts approximately 45-60 minutes with the patient. She begins by introducing us and explain why she is interviewing the patient. She asks the patient open-ended questions that allow the patient to express their feelings. During the interview, she obtains approval from the patient for the release of information (ROI) from other providers. My preceptor is thorough and makes a conscious effort to address patient’s questions and concerns while allowing the patient to be an active participant in their treatment plan. She tailors the interview to meet the needs of each specific patient.

Describe the element most helpful in your practice

       I have found that using the same questions to evaluate the patient allows for a detailed review of all facets of the client’s presentation, as well as the identification of any current issues. The interview format was inspired by similar ones used by my preceptors, and I have seen how successful it is to use the same set of assessment questions for each patient.

References

Carlat, D.J. (2017). The psychiatric interview (4th ed.). Philadelphia, PA: Wolters Kluwer.

Norris, A.E., Torres-Thomas, S., & Williams, Ellita, T. (2014). Adapting cognitive interviewing for early adolescent hispanic girls and sensitive topics. Hispanic Health Care International, 12(3), 111-119. https://doi-org.ezp.waldenulibrary.org/10.1891/1540-4153.12.3.111

Sadock, B.J., Sadock, V.A., Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

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