Which diagnostic evaluations and treatment plan elements should be recorded in the patient's health record following a history and Mental Status Examination (MSE)?

Updated: Sep 24, 2020
  • Author: Jeffrey S Forrest, MD; Chief Editor: David Bienenfeld, MD  more...
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Perform a complete physical examination, including a neurological examination. Obtaining collateral information from family members, friends, and colleagues is important. These individuals all can help in formulating an accurate account of the events that led to the patient's visit to the psychiatrist. Note the following:

  • Psychological evaluation: Some evaluations require a battery of psychological tests, including neuropsychological testing when deemed appropriate. This series of tests can help determine what types of deficits the patient might have, can help identify any Axis II diagnoses, and can help identify other factors, such as factitious disorders or malingering.

  • Laboratory testing (See Lab studies in Treatment Plan.)

  • Diagnosis: Use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5) [6]

  • Differential diagnosis: Determine the patient's differential diagnosis, for both medical and psychiatric illnesses, based on all information gathered from the patient interview, MSE, psychological testing, review of medical history, and current laboratory reports.

  • Formulation: Use the biopsychosocial model. The formulation is for the current situation and identifies the specific event, state of mind, topics of concern and defense mechanism(s) used, relationships, and the strengths that the patient brings to the treatment setting. The Cultural Formulation is appropriate for patients from various cultural backgrounds.

  • Treatment: The treatment approach that is best suited as a starting point should be noted, including psychotherapeutic, psychopharmacologic, behavioral, and social interventions. This also is an excellent place to document further consultations that are deemed necessary. A statement regarding the patient's agreement (or lack thereof) with participating in the various portions of the recommended treatment also is wise to add.

  • Prognosis: Patients' prognoses are dependent on the specific illness with which they are diagnosed. However, patients should be encouraged to pursue treatment regardless of their prognosis and should be encouraged to be compliant with the treatment plans formulated for them. Make them understand that their prognosis is always better when they are compliant with medications and follow-up appointments and instructions.

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