Speciality: Psychiatrist

Download the Essential Checklist for General Psychiatry New Patient Assessments (Community Version – UK)

-> Ensure your psychiatric assessments are thorough, professional, and person-centred with our expertly crafted checklist by completing the form. Designed specifically for UK community settings, this resource helps you structure detailed, accurate, and ethical notes from first contact.

Template Structure

Medication

This section should only be completed if the patient’s current medication is explicitly mentioned within the transcript, contextual notes, or existing clinical documentation. If no medication is discussed or referenced, leave this section blank.

Care Plan

Include the care plan only when specific details are provided in the transcript, contextual notes, or clinical entry. If no care plan is discussed or referenced, do not add content in this section.

At [insert clinic name], we strive to prioritise patients who are experiencing difficulties by offering earlier appointments when possible. However, as this is not an emergency service, anyone in immediate crisis is advised to contact [insert emergency service]. The urgent mental health support line is [insert emergency contact details]. Patients may also seek urgent care through their GP. For medical emergencies, dial 999 or proceed to the nearest Accident and Emergency department.

The consultation took place with [insert patient’s name], conducted [specify in person or via video], through [insert clinic name].

Presenting Complaint

Document the main issue or reason for the consultation if this has been clearly stated in the transcript or accompanying notes. If not provided, omit this section.

History of Presenting Complaint

Include the onset of symptoms and a description of how they have progressed over time, only if these details are mentioned explicitly in the available documentation.

Past Psychiatric History

Detail any previous psychiatric diagnoses or treatments. This includes any known history of mental health conditions, hospitalisations, or therapeutic interventions the patient has undergone.

Relevant Medical History

Summarise any current physical health conditions or relevant past diagnoses and list any non-psychiatric medications, but only if explicitly stated.

Allergies

Note any known drug allergies, if mentioned in the transcript or clinical documentation.

Substance Use

Provide information about the patient’s current or past use of alcohol or recreational substances, including the type and amount used. Mention any efforts made by the patient to manage or reduce substance use if this has been disclosed.

Family History

Record any known psychiatric conditions in the patient’s family, noting both positive and explicitly stated negative findings. Include information on significant physical health conditions that may run in the family, where applicable.

Living Situation

Describe the patient's current living arrangements if this has been discussed.

Personal History

[Include birth and developmental history only when these details are provided.]

[Outline the family background, including relationships with parents, siblings, or other primary caregivers.]

[Mention any adverse childhood experiences, such as trauma, abuse, or difficult family relationships.]

[Reflect on school life, including behaviour in the classroom, academic focus, organisational skills, experiences with peers, and any symptoms suggestive of ADHD, if discussed.]

[Note academic qualifications and educational milestones, such as A-levels or university attendance.]

[Document the patient’s work history and any reported difficulties with employment or workplace relationships.]

[Capture information on romantic or social relationships, if this has been shared.]

Mental State Examination

Record findings from the mental state examination only if these are noted in the transcript or clinical notes. This should cover appearance, behaviour, speech, mood and affect, thought processes, perceptual disturbances, cognition, insight, and judgment.

Discussion

Summarise the discussion of the assessment and the plan going forward, but only include information directly referenced in the source material.

Physical Health Parameters

Include any relevant physical health metrics or concerns only if these are specifically documented.