How to Transcribe a Psychiatric Assessment Report

How to Transcribe a Psychiatric www.medicaltranscriptionservicecompany.com

Assessment Report -

www.medicaltranscriptionservicecompany.com When a patient is admitted to a hospital or outpatient mental health program and discharged from the health care organization, a full psychiatric evaluation is performed. In psychiatric evaluation, the psychiatrist who specializes in the relevant area of psychiatry will ask both patients and family members a lot of personal questions. The examiner’s observations will provide other specific information. The information thus collected is transcribed to obtain a comprehensive report known as the Psychiatric Assessment Report. It is based on this report that the psychiatrist develops a treatment plan and refers to on future visits. A comprehensive psychiatric assessment report would include the following details:

Elements of the Psychiatric Assessment 

Presenting the Problem – The first thing a psychiatric assessment report should clarify is the reason why a patient visits the relevant health care institution. If the exact words of patient or other informant are included in the answer (for example, “I was feeling dizzy for an entire week and lost appetite), they should be placed in quotes. Typically, ‘Reason for Referral’ is the heading for presenting a problem in a consultation report. It may be ‘History of Present Illness’ or ‘Reason for Consultation’ in case of a hospital or clinic. Another option is ‘Chief Complaint’. The details of the problem presented can be quite long depending on the condition of the patient.

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Past Psychiatric History – The details about any previous mental health treatment or diagnoses the patient has received should be included in this section. This is can also be quite long. If the patient has not received any previous mental health treatment or diagnoses, it can be transcribed as PAST PSYCHIATRIC HISTORY: Denied.

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Substance Abuse – The information on the substance use or abuse by patients are included in this section. These details are either self-reported or can be found from past medical records. The title may vary as ‘ALCOHOL AND DRUGS’ or ‘SUBSTANCE ABUSE’. It can be transcribed as ‘SUBSTANCE ABUSE: Denies’ if the patient does not use or abuse substance and has no history of treatment for alcohol or drug problems.

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Past Medical History – Significant or ongoing medical conditions or surgeries are listed in this section. There is no need to place numbers against the conditions or surgeries if they are not mentioned in the dictation.

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Family History – The mental health problems of immediate relatives of patients such as parents, siblings and children should be described in this section. This would include details of mental health history (for example, schizophrenia, alcoholism, suicide). Family medical issues considered to be potentially relevant and often placed under a separate heading. Here is an example: FAMILY PSYCHIATRIC HISTORY His son has ADHD. No known family history of suicidal attempts. No history of drug or alcohol abuse in the family

www.medicaltranscriptionservicecompany.com FAMILY MEDICAL HISTORY His father has diabetes. His mother has migraines 

Social History – This section typically begins with the demographic details regarding the patient’s circumstances of birth and progression chronologically to current living situations. Relationships, children, deaths, relocation, and traumatic occurrences can be described. Educational level and work history can be also mentioned. If the patient has/had any legal issues (for example, criminal charges, conviction), they should be listed out in this section.

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Current Medications – Medications taken by patients by the patient on a regular basis are listed under this head. This section can be dictated as a numbered list or a paragraph. If the medications are numbered in the dictation, they should be listed vertically along with a period at the end of each medication (as given below): CURRENT MEDICATIONS 1. Lexapro 10 mg per day.

2. Seroquel XR 200 mg per day.

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Mental Status Examination – This section assesses the current mental state including the description of patient’s appearance, mood, attitude, thought process, behavior and other aspect of the condition. In this case, dictators tend to stick on their favorite phrases which the transcriptionist would need to add into their word expander.

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Diagnoses – Psychiatric diagnoses are expressed in a five-part structure known as multi-axial system in which each axis refers to a different aspect of the patient’s condition and may include multiple items. Roman numerals are used to represent axis number. Since the axis number and the diagnoses associated with it would be stated in the dictation, the resulting structure would be as follows: DIAGNOSES Axis I Schizophrenia, Paranoid Type .

Axis II Deferred.

Axis III Hyperlipidemia.

Axis IV Lacks familial and social support.

Axis V GAF is 30.

As per facility preference, the axis number and associated heading can be written on the same line or separate lines. If they are written on the same line, the text should be separated by a tab as shown as below.

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DIAGNOSES Axis Axis Axis Axis Axis

I: Schizophrenia, Paranoid Type .

II: Deferred.

III: Hyperlipidemia.

IV: Lacks familial and social support.

V: GAF is 30.

Specific wording (DSM) published diagnoses. Extra placed at the end

from the Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association is used for psychiatric letters including R for revised edition or TR for text revision are as given below

DSM-III-R DSM-IV DSM-IV-TR 

Treatment Plan – This is the final section where the next steps for the patient are listed such as hospital admission, medication changes, or followup appointments.

Importance of Accurate Documentation The major purposes of documentation is to communicate clinical information to current and future providers, remind the clinician of what has happened so far in treatment, defend the clinician in a malpractice issue, convince accrediting agencies, and justify care to third party payers. Accurate documentation is crucial to achieve these goals. 

Good documentation is the core evidence in every malpractice trial and it can stop many malpractice cases from proceeding.

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Courts expect the clinician to use ‘reasonable professional judgment’ after thoroughly considering the factual/clinical data. If the reasoning is properly documented, it will provide evidence that the clinician was thoughtful and used reasonable professional judgment.

A medical transcriptionist usually receives psychiatric assessment in the form of consultation report or discharge summary which includes the following:       

Reason for admission/referral Previous psychiatric history Concerns on substance abuse Family and personal social history Medical status (includes physical ailments, current medications) Current mental status (according to the assessment of the examiner) Psychiatric diagnoses or possible diagnoses

www.medicaltranscriptionservicecompany.com A report that includes the input from family members or other people in patient’s social circle will be quite lengthy and take longer to transcribe. Psychiatrists can ensure complete and accurate assessment reports with the help of experienced, trained medical transcriptionists in a professional medical transcription company that offers psychiatry transcription service.

About The Author MTS Transcription Services (MTS) is a US-based medical transcription company, committed to provide HIPAA compliant medical transcription services for healthcare providers. We offer quality medical transcription outsourcing services to hospitals, clinics and healthcare facilities of all major specialties including pediatrics, pathology, orthopedics, cardiology and more.

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