Psychiatric Assessment Template

Identification: John Doe, 45, Male
Chief Complaint: "I have been feeling extremely anxious and unable to sleep for the past few weeks."
History of Present Illness:  
John Doe reports a gradual onset of anxiety symptoms over the past month, with increasing severity. He describes difficulty sleeping, feeling restless, and experiencing frequent panic attacks.
Psychiatric review of systems:  
Depressive symptoms: John reports feeling hopeless and having a lack of interest in activities he once enjoyed.  
Anxiety symptoms: He experiences constant worry, restlessness, and panic attacks.  
Sleep: John has difficulty falling asleep and staying asleep, often waking up multiple times during the night.  
Suicidal and homicidal ideations: John denies any suicidal or homicidal ideations or plans.  
Auditory and visual hallucinations: He denies experiencing any hallucinations.  
Delusions/paranoia: John denies any delusional or paranoid thinking.  
Manic symptoms: He denies any manic or hypomanic symptoms.  
PTSD: John reports flashbacks and nightmares related to a past traumatic event.  
OCD: He denies any obsessive-compulsive symptoms.
Past Psychiatric History:  
Prior diagnosis: Generalized Anxiety Disorder, Major Depressive Disorder  
Hospitalizations in psychiatric units: None  
Previous suicide attempts: None  
History of self harm: None  
Access to firearms: No access to firearms  
Psychotropic medications: Currently taking Sertraline 50mg daily  
Current psychiatrist and therapist: Dr. Emily Smith, Therapist: Sarah Johnson  
Cures report: Available
Family History of psychiatric/substance use history: John's mother had a history of depression and his father struggled with alcohol use disorder.
Legal History: No history of legal issues.
Trauma History: John experienced emotional abuse during childhood, which was not reported to legal authorities.
Substance Use History:  
Participation in outpatient or inpatient levels of care for substance use: None  
Alcohol: Occasional social drinking  
Cannabis: Denies use  
Amphetamines: Denies use  
Nicotine: Smokes half a pack of cigarettes daily  
Other substances: Denies use
Medical History: Reports a history of migraines and denies any head trauma or seizures.
Medical Review of Systems: No significant findings.
Current Medications: Sertraline 50mg daily  
Historical Medications: Previously tried Fluoxetine, experienced nausea as a side effect
Drug Allergies: None known
Allergies: None known
Social History:  
Marital Status: Married  
Children: Two children, ages 10 and 15  
Living situation: Lives with spouse and children  
Employment: Works as a software engineer  
Education: Bachelor's degree in Computer Science  
Support System: Strong support from family and friends
Objective:  
Mental Status Evaluation:  
Appearance: Well-groomed, casually dressed  
Cognition: Alert and oriented to person, place, and time  
Speech: Normal rate and volume  
Mood: Anxious  
Affect: Congruent with mood  
TP: Linear and goal-directed  
TC: No evidence of delusions or hallucinations  
Perc: No perceptual disturbances noted  
Insight/Judgment: Good insight and judgment
Assessment:  
John presents with symptoms of anxiety and depression, consistent with Generalized Anxiety Disorder and Major Depressive Disorder.
Plan:  
1. Risk Assessment: Low risk for self-harm or harm to others, protective factors include strong family support.  
2. Status: Voluntary  
3. Diagnostics: No additional tests required at this time  
4. Treatment:  
5. Bio: Continue Sertraline 50mg daily, discuss potential side effects and benefits  
6. Psychosocial: Cognitive Behavioral Therapy (CBT) sessions weekly, safety planning  
7. Patient's Participation in treatment plan: John is willing to engage in therapy and medication management
Therapeutic Interventions: CBT, 60-minute session  
Symptoms or Challenges Discussed: Anxiety management, sleep hygiene  
Impact on the Patient's Functioning: Anxiety significantly impacts John's work performance and social interactions  
Specific Topics Covered: Coping strategies, relaxation techniques  
Client's Response: John is receptive to therapy and actively participates  
Prognosis: Good, with continued treatment and support
Diagnosis:  
Generalized Anxiety Disorder (F41.1)  
Major Depressive Disorder, Recurrent, Moderate (F33.1)
Billing Codes:  
99205, 90837
Provider's name:  
Nurse Jane Thompson