Synopsis
Obtain a collaborative psychiatric history, describe the mental state precisely, assess immediate risk and capacity, and integrate medical, neurological, substance, developmental and social explanations without turning observation into unsupported diagnosis.
- Begin with the person's account and priorities, then establish a dated chronology of symptoms, function, treatment, physical health, substances, development, relationships and previous episodes.
- Explain privacy and its limits before sensitive questions; use a professional interpreter and communication adjustments rather than relying on relatives to translate clinical or risk information.
- The mental-state examination is a description made during the encounter: appearance and behaviour, speech, mood and affect, thought, perception, cognition, insight and judgement.
Key red flags
Fluctuating attention or arousal, disorientation, fever, hypoxia, head injury, seizure, focal neurology or a new medicine exposure suggests an acute medical or neurological syndrome rather than uncomplicated primary psychiatric illness.
Investigation priorities
Define symptoms, course, context, impairment, previous episodes, treatments and the person's goals.
Management branches
A person presents for psychiatric assessment in any clinical setting.
- Check immediate physical safety, privacy, communication needs and whether another person should be present before beginning a broad invitation.
- Build a dated account of symptoms, function, context, treatments and previous episodes, moving from open questions to focused clarification.