8.1 KiB
8.1 KiB
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] |