[Music]
let's talk now about the components of
the psychiatric history and assessment
when taking a history from a patient
forming a therapeutic alliance is going
to lay the foundation for your work with
that patient so making an alliance is
extremely a port important here are a
few tips to help you build that strong
bond with your patient first don't
forget to introduce yourself allow the
patient to feel comfortable by creating
a room in an atmosphere that's inviting
and welcoming for them also invite your
patient to share a narrative or a story
avoid asking yes and no questions but
rather open the floor to them and be
non-judgmental as they tell you what's
on their mind always follow your
patients lead they may go off on
tangents but it's important to follow
their train of thought this helps them
feel comfortable and it lets them feel
as if they can trust you also in that
very first encounter remember to respect
the patient's wishes to avoid certain
subjects you can always come back to it
later and finally staff safety is just
as important as patient safety therefore
before initiating an encounter with any
patient make sure that the room is
staged in a way that people feel
comfortable and also exits are easily
accessible for the patient and staff
alike taking a patient's history
involves several components that are all
very important for example begin with
open-ended questions and then you can
always narrow down your approach based
off of that patients chief complaint
explore the present illness with the
patient asked them about their symptoms
what precipitated this event what kind
of social setting they're in and what
kind of supports they have be curious
about their current and past treatment
options and complications that they've
had also collect thorough information
this is a psychiatric assessment
it's extremely important that not only
do you ask about psychiatric history you
also inquire about medical and surgical
history ask about substance abuse
history family history medications that
the patient is taking their allergies
and safety including not only their
present safety but past suicidal and
homicidal thoughts consider their social
history and their developmental history
finally when taking the Mental Status
exam this is a critical component of the
psychiatric assessment it's basically
equivalent to what you do in medicine
when you do a physical exam the Mental
Status exam includes your observations
direct questions to the patient about
their thoughts beliefs perceptions and
cognition and it also creates a picture
of the patient
so consider the Mental Status exam as
something that you can use as a tool to
describe them to peers colleagues and
other members of the treatment team they
should be able to formulate a picture of
the patient without having ever met them
solely based off of your descriptions
from their mental status exam when you
formulate a patient there are a couple
of things to consider first of all
depending on your setting you may be
referring to diagnostic criteria
according to an icd-10 or dsm-5 coding
system also it's important to take a
biopsychosocial approach to the patient
when you're formulating their illness
and also their treatment and their
future trajectory the biopsychosocial
approach includes things like
considering biological psychological and
social predisposing precipitating and
perpetuating factors that are
interfering with one's ability to
achieve the best of mental health
[Music]