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SOPs/Clinical-Services/SOP-MHO-001-Initial-Evaluation.md

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+# Standard Operating Procedure: Outpatient Mental Health Initial Evaluation
+
+| Document ID | SOP-MHO-001 |
+|-------------|-------------|
+| Title | Outpatient Mental Health Initial Evaluation |
+| Revision | 1.0 |
+| Effective Date | [DATE] |
+| Author | [AUTHOR] |
+| Approved By | [APPROVER] |
+| Department | Outpatient Mental Health |
+
+---
+
+## 1. Purpose
+
+To establish standardized procedures for conducting comprehensive initial mental health evaluations for new outpatient patients to ensure accurate diagnosis, appropriate treatment planning, and regulatory compliance.
+
+## 2. Scope
+
+This procedure applies to all initial evaluations for outpatient mental health services including:
+- Adult psychiatric evaluation
+- Child/adolescent psychiatric evaluation
+- Psychological evaluation
+- Intake assessment for therapy
+- Medication management evaluation
+- Telehealth evaluations
+
+## 3. Responsibilities
+
+### 3.1 Psychiatrist/Psychiatric NP/PA
+- Conduct psychiatric diagnostic evaluation
+- Establish diagnoses
+- Initiate medication treatment
+- Refer for therapy as indicated
+
+### 3.2 Therapist/Counselor
+- Conduct therapy intake assessment
+- Establish treatment goals
+- Initiate therapy services
+- Coordinate care with prescriber
+
+### 3.3 Psychologist
+- Conduct psychological evaluations
+- Administer psychological testing
+- Provide diagnostic clarification
+- Treatment recommendations
+
+### 3.4 Support Staff
+- Schedule evaluations appropriately
+- Collect intake paperwork
+- Verify insurance and authorizations
+- Facilitate check-in process
+
+## 4. Definitions
+
+| Term | Definition |
+|------|------------|
+| Chief Complaint | Primary reason for seeking treatment |
+| Mental Status Examination | Structured assessment of current mental functioning |
+| DSM-5 | Diagnostic and Statistical Manual of Mental Disorders, 5th Edition |
+| PHQ-9 | Patient Health Questionnaire (depression screen) |
+| GAD-7 | Generalized Anxiety Disorder scale |
+
+## 5. Procedure
+
+### 5.1 Pre-Evaluation Preparation
+
+#### 5.1.1 Intake Paperwork
+Complete prior to evaluation:
+- [ ] Demographic information
+- [ ] Insurance information
+- [ ] Consent for treatment
+- [ ] HIPAA acknowledgment
+- [ ] Release of information (prior providers)
+- [ ] Symptom questionnaires
+- [ ] Medical history form
+- [ ] Medication list
+
+#### 5.1.2 Records Review
+If available, review:
+- Prior mental health records
+- Recent medical records
+- Hospitalization summaries
+- Previous psychological testing
+- Current medication list
+
+### 5.2 Initial Evaluation Components
+
+#### 5.2.1 Psychiatric Diagnostic Evaluation
+
+**Chief Complaint and Present Illness**
+- Current symptoms in patient's words
+- Onset and duration
+- Severity and frequency
+- Impact on functioning
+- Precipitating factors
+- What has helped/not helped
+
+**Psychiatric History**
+| Element | Detail |
+|---------|--------|
+| Previous diagnoses | |
+| Previous hospitalizations | Dates, location, reason |
+| Previous outpatient treatment | Providers, duration, helpfulness |
+| Previous medications | Name, dose, response, side effects |
+| ECT/TMS/other treatments | |
+| Suicide attempts | Method, intent, lethality, medical treatment |
+| Self-harm history | |
+| Violent behavior | |
+
+**Substance Use History**
+| Substance | Ever Used | Current Use | Last Use | Quantity/Frequency |
+|-----------|-----------|-------------|----------|---------------------|
+| Alcohol | ☐ | ☐ | | |
+| Cannabis | ☐ | ☐ | | |
+| Opioids | ☐ | ☐ | | |
+| Stimulants | ☐ | ☐ | | |
+| Benzodiazepines | ☐ | ☐ | | |
+| Tobacco/Nicotine | ☐ | ☐ | | |
+| Other | ☐ | ☐ | | |
+
+- Substance use treatment history
+- Withdrawal history
+- Periods of sobriety
+
+**Medical History**
+- Chronic conditions
+- Current medications
+- Allergies (medications, environmental, food)
+- Recent labs (if available)
+- Primary care provider
+
+**Family History**
+- Psychiatric disorders
+- Substance use disorders
+- Suicide
+- Response to medications (if known)
+
+**Social History**
+| Domain | Information |
+|--------|-------------|
+| Education | Highest level, any difficulties |
+| Employment | Current status, history |
+| Living situation | With whom, stability |
+| Relationships | Marital status, support system |
+| Legal | Current or pending legal issues |
+| Trauma history | Abuse, neglect, other trauma |
+| Military | Branch, combat exposure, discharge status |
+| Cultural/spiritual | Relevant beliefs/practices |
+
+**Developmental History** (especially for children/adolescents)
+- Pregnancy/birth complications
+- Developmental milestones
+- School performance
+- Peer relationships
+- Behavioral issues
+
+**Mental Status Examination**
+| Domain | Findings |
+|--------|----------|
+| Appearance | Dress, grooming, hygiene, apparent age |
+| Psychomotor | Activity level, retardation, agitation |
+| Attitude | Cooperative, guarded, hostile |
+| Eye contact | Good, poor, variable |
+| Speech | Rate, rhythm, volume, coherence |
+| Mood | Patient's stated mood |
+| Affect | Range, congruence, appropriateness |
+| Thought process | Linear, tangential, circumstantial, loose |
+| Thought content | Delusions, obsessions, preoccupations |
+| Perceptions | Hallucinations (type), illusions |
+| Cognition | Orientation, attention, memory |
+| Insight | Good, fair, poor |
+| Judgment | Good, fair, poor |
+
+**Risk Assessment**
+| Risk | Assessment |
+|------|------------|
+| Suicide | Ideation, plan, intent, means, attempts |
+| Violence | Ideation, target, plan, history |
+| Self-harm | Current urges, methods, history |
+| Risk level | Low / Moderate / High |
+
+**Diagnosis (DSM-5)**
+| Priority | Diagnosis | ICD-10 Code |
+|----------|-----------|-------------|
+| Primary | | |
+| Secondary | | |
+| Additional | | |
+| Substance | | |
+| Medical | | |
+
+**Treatment Plan**
+- Medication recommendations
+- Therapy recommendations
+- Frequency of follow-up
+- Laboratory monitoring
+- Referrals
+- Patient goals
+
+### 5.3 Standardized Assessments
+
+Administer as indicated:
+| Assessment | Population | Purpose |
+|------------|------------|---------|
+| PHQ-9 | Adults | Depression severity |
+| GAD-7 | Adults | Anxiety severity |
+| C-SSRS | All | Suicide risk |
+| MDQ | Mood disorders | Bipolar screening |
+| ASRS | Adults | ADHD screening |
+| PCL-5 | Trauma history | PTSD screening |
+| AUDIT | Alcohol use | Alcohol use disorder |
+| DAST-10 | Drug use | Drug use disorder |
+
+### 5.4 Informed Consent
+
+Discuss and document:
+- Nature of recommended treatment
+- Expected benefits
+- Potential risks and side effects
+- Alternatives (including no treatment)
+- Right to refuse or withdraw
+- Confidentiality and limits
+- Emergency procedures
+
+### 5.5 Safety Planning
+
+For patients with elevated risk:
+- [ ] Complete safety plan (FRM-MHO-002)
+- [ ] Provide crisis resources
+- [ ] Establish emergency contact
+- [ ] Reduce access to means
+- [ ] Schedule appropriate follow-up
+
+### 5.6 Care Coordination
+
+- [ ] Request records from prior providers
+- [ ] Communicate with PCP as indicated
+- [ ] Coordinate with other treaters
+- [ ] Referral to appropriate level of care if needed
+
+## 6. Special Considerations
+
+### 6.1 Telehealth Evaluations
+- Verify patient location and identity
+- Confirm emergency contact and local resources
+- Assess appropriateness for telehealth
+- Document telehealth consent
+
+### 6.2 Child/Adolescent Evaluations
+- Include parent/guardian interview
+- School information as relevant
+- Developmentally appropriate assessment
+- Assent/consent as appropriate
+
+### 6.3 Geriatric Evaluations
+- Cognitive screening
+- Capacity assessment if concerns
+- Medical complexity consideration
+- Caregiver involvement
+
+## 7. Documentation
+
+- Initial evaluation note (complete within 72 hours of visit)
+- Consent forms
+- Standardized assessment scores
+- Safety plan (if applicable)
+- Release of information forms
+
+## 8. Quality Metrics
+
+| Metric | Target |
+|--------|--------|
+| Evaluation completed within scheduled time | >90% |
+| Documentation complete within 72 hours | 100% |
+| Suicide risk assessment documented | 100% |
+| Treatment plan documented | 100% |
+| Follow-up scheduled | 100% |
+
+## 9. References
+
+- American Psychiatric Association Practice Guidelines
+- DSM-5 Diagnostic Criteria
+- State mental health regulations
+- Payer documentation requirements
+
+---
+
+## Revision History
+
+| Rev | Date | Description | Author |
+|-----|------|-------------|--------|
+| 1.0 | [DATE] | Initial release | [AUTHOR] |