Psychiatric Evaluation
A formal physician-authored document recording a patient's presenting complaint, psychiatric and medical history, mental status, diagnostic impressions, and initial treatment plan at the time of admission.
Full Definition
A psychiatric evaluation (also called an initial psychiatric evaluation or admission psychiatric evaluation) is a structured clinical document completed by a psychiatrist or qualified licensed independent practitioner upon a patient's admission to a psychiatric facility. It encompasses the chief complaint, history of present illness, past psychiatric and substance use history, medical and family history, mental status examination findings, DSM diagnostic formulation, and initial treatment plan. Joint Commission standards mandate completion within 60 hours of admission in most settings. Editors must preserve clinician-authored diagnostic language precisely; altering symptom descriptors can have medico-legal consequences.
Usage
Usage note: Do not shorten to 'psych eval' in formal documents. Distinguish clearly from the nursing assessment and the psychosocial assessment, which are authored by different disciplines.
In Context
- "The attending psychiatrist's psychiatric evaluation documented a five-year history of treatment-resistant major depressive disorder with two prior inpatient admissions." — Admission psychiatric evaluation
- "The quality review identified eleven cases in which the psychiatric evaluation was not completed within the required 60-hour window." — Quality improvement report