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This new Pocket Guide, based on the 2015 edition of the Practice Guidelines for the Psychiatric Evaluation of Adults, focuses on the initial psychiatric evaluation, including additional domains of evaluation relevant to CPT documentation requirements. The Guide covers aspects of the Chief Complaint; History of Present Illness; Psychiatric, Substance Use, Family, Personal and Social, and Medical Histories; Review of Systems; Examination, including Mental Status Examination; Review of Available Data; and Formulation, Diagnostic Impression, and Treatment Plan.
Section I: Chief Complaint
Section II: History of Present Illness
Section III: Psychiatric History
Section IV: Substance Use History
Section V: Family History
Section VI: Personal and Social History
Section VII: Medical History
Section VIII: Review of Systems
Section IX: Examination, Including Mental Status Examination
Section X: Constitutional
Section XI: Musculoskeletal
Section XII: Psychiatric Examination
Section XIII: Review of Available Data
Section XIV: Formulation, Diagnostic Impression and Plan