Psych history taking checklist

Question 1

PSYCH - OPENING CONSULT

Answer 1

Question 2

PSYCH - PC AND HPC

Answer 2

Question 3

PSCYH - PAST PSYCH AND FORENSIC

Answer 3

Question 4

PSCYH PMH

Answer 4

Question 5

PSYCH - DRUG

Answer 5

Question 6

PSYCH - FH

Answer 6

Question 7

PSYCH - PERSONAL HISOTRU

Answer 7

Question 8

PSYCH - SOCIAL HISTORY

Answer 8

Question 9

PSYCH INSIGHT

Answer 9

Question 10

PSYCH - CLOSING

Answer 10

Question 11

PSYCH COMMUNCIATION

Answer 11

Question 12

CHECKLIST PSYCH SUMMARY

Answer 12

Opening the consultation
1 Wash your hands and don PPE if appropriate
2 Introduce yourself to the patient including your name and role
3 Confirm the patient’s name and date of birth
4 Explain that some questions may be difficult to answer
5 Ask the patient if they’d be happy to talk with you about their current issues
6 Establish the status of their admission (informal or detained under Mental Health Act)
Presenting complaint
7 Use open questioning to explore the patient’s presenting complaint
History of presenting complaint
8 Explore the presenting complaint in more detail
9 Conduct a risk assessment
10 Consider taking a collateral history
11 Explore the patient’s ideas, concerns and expectations
12 Summarise the patient’s presenting complaint
Past psychiatric history
13 Ask the patient about their past psychiatric history
14 Establish past psychiatric diagnoses, treatments and past contact with mental health
services
Forensic history
15 Ask the patient about their forensic history
Past medical history
16 Ask if the patient has any medical conditions
17 Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the
substance (e.g. mild rash vs anaphylaxis)
Drug history
18 Ask if the patient is currently taking any prescribed medications or over-the-counter
remedies
19 Ask about recent medication changes
20 Ask the patient if they’re currently experiencing any side effects from their medication
Family history
21 Ask the patient if there is any family history of psychiatric or physical disease
Personal history
22 Ask the patient about their childhood
23 Ask about schooling and education
24 Ask the patient about their occupation and employment history
25 Ask the patient about their current and previous interpersonal relationships
26 Ask the patient about their pre-morbid personality
Social history
27 Ask about the patient’s current living circumstances
28 Ask about any children at home and identify any safeguarding issues
29 Ask the patient about their activities of daily living
30 Take a smoking history
31 Take an alcohol history
32 Ask about recreational drug use
Insight
33 Assess the patient’s insight
Closing the consultation
34 Summarise the salient points of the history back to the patient and ask if they feel anything
has been missed
35 Thank the patient for their time
36 Dispose of PPE appropriately and wash your hands
Key communication skills
37 Active listening
38 Summarising
39 Signposting