Definition
A psychiatric history is the result of a medical process, where a clinician working in the field of mental health systemically records the content of an interview.
History Collection in psychiatric patients is a critical process aimed at understanding the patient’s mental health condition, identifying contributing factors, and planning effective care. Here’s a structured approach:
1. Identification Data
- Collect basic information such as the patient’s name, age, gender, marital status, occupation, and contact details.
2. Chief Complaint
- Document the patient’s primary reason for seeking help, including specific symptoms or concerns.
3. History of Present Illness
- Explore the onset, duration, and progression of symptoms.
- Identify triggers, stressors, or events that may have contributed to the condition.
- Assess the impact of symptoms on daily functioning.
4. Past Psychiatric History
- Review previous mental health diagnoses, treatments, hospitalizations, or therapy sessions.
- Note any history of self-harm, suicidal ideation, or substance use.
5. Medical and Medication History
- Document past and current medical conditions.
- Review medications, including psychiatric drugs, and their effectiveness or side effects.
6. Family History
- Assess for a family history of mental health disorders, substance abuse, or genetic predispositions.
7. Personal and Social History
- Explore the patient’s upbringing, education, relationships, and employment history.
- Assess social support systems and living conditions.
8. Substance Use History
- Evaluate the use of alcohol, drugs, or tobacco, and their impact on mental health.
9. Premorbid Personality
- Understand the patient’s personality traits and coping mechanisms before the onset of the illness.
10. Risk Assessment
- Assess for risks of self-harm, harm to others, or neglect.
- Identify protective factors and coping strategies.
11. Mental State Examination (MSE)
- Conduct an MSE to evaluate appearance, behavior, mood, thought processes, perceptions, cognition, and insight.
Outline of Psychiatric History
- Personal data: Name, age, marital status, occupation, address.
- Informant data: Name, relationship to patient and your impression of the informant’s reliability.
- Reason for referral/visit to psychiatric facility: The immediate reason which cause the patient to seek treatment/be brought to the hospital.
- Presenting complaints and duration: The symptoms in brief and their duration.
- History of presenting complaints:
- A description of the symptoms and duration including: How the symptoms began and how the symptoms changed with time, e.g., increasing gradually or stepwise/remained same/episodic in nature).
- Change in biological functions, e.g., sleep, appetite, weight.
- Effect of symptoms on patient’s relationships, day-to-day activities and work.
- Association between symptoms and any stressors or life events.
- Any other relevant information.
6.Stressors: Psychological or physical.
7. Physical history
- Age and occupation of parents and relationship with one another.
- General information about siblings.
- Social standing of the family.
- History of psychiatric illness, suicide or substance abuse in the family
- Any other relevant information.
8. Personal history
- Antenatal and birth history.
- Early developmental history.
- Health in childhood.
- Occupational history.
- Marital history.
- Social history.
9.History of substance use
- History of substance use such as alcohol, nicotine, cocaine or other drugs.
- Duration of use, amount using at present and frequency of use.
- Associated problems, e.g., legal/financial/social, secondary to substance misuse.
10.Past medical and surgical history
- Past psychiatric history
- Does the patient have past history of psychiatric illness? When?
- Was the illness episodic? Or was the patient continuously unwell.
- Nature of treatment received and response to treatment? Why?
- Drug adherence.
- Premorbid personality: This is an attempt to get an idea about what sort of a person the patient was before he/she fell ill.
- Relationships.
- Leisure activities.
- Character.
- Attitude and standards.
- Prevailing mood.
Assessment of Mental Status
- Appearance and behavior:
- General appearance.
- Posture and movement.
- Attitude towards examiner.
- Speech:
- Rate of speech.
- Flow of speech.
- Content of speech.
- Volume of speech.
- Mood:
- Anxious.
- Depressed.
- Elated.
- Irritable.
- Angry.
- Content of thought:
- Pre-occupation and/or worries.
- Ideas and plans of suicide.
- Ideas and plans/impulses/images and compulsive rituals.
- Delusions/overvalued ideas.
- Disorders of perception:
- Hallucinations: Auditory, visual, olfactory, gustatory, tactile.
- Illusions.
- Cognitive functions:
- Level of consciousness.
- Orientation of time, place and person.
- Attention and concentration. Memory-short-term and long-term.
- Intelligence.
- Patient’s understanding of illness/insight.
Nursing Considerations
Nursing considerations for history taking in psychiatric patients emphasize creating a safe, supportive, and nonjudgmental environment to ensure accurate and comprehensive information gathering. Here are key considerations:
1. Establishing Rapport
- Build trust by using a calm, empathetic, and nonjudgmental approach.
- Ensure the patient feels comfortable and respected throughout the process.
2. Privacy and Confidentiality
- Conduct the interview in a private setting to maintain confidentiality.
- Explain how the information will be used and reassure the patient about data protection.
3. Communication Techniques
- Use open-ended questions to encourage detailed responses.
- Avoid leading questions or assumptions about the patient’s experiences.
- Be patient and allow time for the patient to express themselves.
4. Cultural Sensitivity
- Be aware of cultural differences that may influence the patient’s perception of mental health.
- Adapt communication styles to align with the patient’s cultural background.
5. Observation Skills
- Pay attention to nonverbal cues, such as body language, facial expressions, and tone of voice.
- Note any inconsistencies between verbal and nonverbal communication.
6. Comprehensive Data Collection
- Gather information on the patient’s presenting complaints, history of illness, family history, and social background.
- Include details about substance use, coping mechanisms, and premorbid personality.
7. Risk Assessment
- Assess for risks of self-harm, harm to others, or neglect.
- Identify protective factors and support systems.
8. Documentation
- Record information accurately and systematically for future reference.
- Avoid subjective judgments and focus on factual observations.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- R.Sreevani, A Guide to Mental Health & Psychiatric Nursing, 6th Edition, 2024, Jaypee Publishers, ISBN 978-9366161686
- Sheila L. Videbeck, Psychiatric Nursing, Seventh Edition , 2017, Wolters Kluwer Publications, ISBN: 978- 1496355911
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
Stories are the threads that bind us; through them, we understand each other, grow, and heal.
JOHN NOORD
Connect with “Nurses Lab Editorial Team”
I hope you found this information helpful. Do you have any questions or comments? Kindly write in comments section. Subscribe the Blog with your email so you can stay updated on upcoming events and the latest articles.
