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

# 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

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## Revision History

| Rev | Date | Description | Author |
|-----|------|-------------|--------|
| 1.0 | [DATE] | Initial release | [AUTHOR] |