Psychiatric Diagnostic Evaluation (US)
Assessment Session Template:
A standard psychiatric diagnostic intake with medical services that can be used to support CPT code 90792, typically for an initial evaluation with medical services, by medical prescribers (psychiatrists, psychiatric nurse practitioners, and psychiatry PAs). It captures the medical assessment, physical examination where indicated, labs ordered and reviewed, and the medication plan that distinguishes it from a non-medical diagnostic evaluation, and records diagnoses as DSM-5-TR with ICD-10-CM codes and their supporting criteria. For initial diagnostic intake without medical services, consider using the Intake/Diagnostic Assessment template, which can be used to support CPT code 90791.
Template Structure
Example Output
Template Structure
Encounter Details:
- Date of service; setting/modality (in person or telehealth)
- Evaluating practitioner’s name and credential
- Informants and records reviewed — family, carer, referring provider, care team; prior notes, discharge summaries, outside labs
- Consent and confidentiality — informed consent, telehealth consent, release of information discussed
Reason for Evaluation:
- Referral source and the specific referral question
- Chief complaint in the patient’s own words, quoted directly
History of Present Illness:
- Chronological narrative of the current episode: onset, duration, course, precipitants, symptom detail (frequency, severity, duration, functional consequence), aggravating/alleviating factors, and what prompted presentation now
- Associated neurovegetative symptoms — sleep, appetite, weight, energy, concentration, psychomotor change, libido
- Functional impact — work/school, relationships, self-care, parenting, driving, finances
Past Psychiatric History:
- Prior diagnoses, who made them and when
- Prior treatment episodes, therapy type, length, response, engagement
- Medication trials with dose, duration, response, side effects and reason for discontinuation
- Hospitalisations and higher levels of care, with dates, reasons, voluntary/involuntary status
- Prior suicide attempts and self-harm — method, lethality, intent, consequences, dates
- ECT, TMS, ketamine or other interventional treatments
Substance Use History:
- For each substance referenced: type, route, current pattern, quantity/frequency, age of first use, heaviest use period, last use, tolerance, withdrawal history, prior treatment/abstinence periods
- Screening results referenced (e.g. AUDIT-C, DAST) and DSM-5-TR criteria met if a substance use disorder is being diagnosed
Medical History:
- Current medical conditions, diagnosis date, status, treating providers
- Past medical and surgical history
- Current medications — psychiatric and non-psychiatric — with dose, route, frequency, prescriber; includes OTC/supplements
- Allergies and adverse drug reactions (or “NKDA”)
- Relevant medical review of systems — only systems actually reviewed
- Pregnancy, lactation and contraception status
Family History:
- Psychiatric history in first- and second-degree relatives — diagnoses, suicide, substance use, treatment response
- Relevant family medical history
Social, Developmental and Cultural History:
- Developmental history
- Current living situation and supports
- Education and occupation, including current work impairment
- Legal history and military service
- Social determinants of health — housing, food insecurity, transport, cost barriers, caregiving burden, isolation
- Cultural, linguistic and identity considerations — language, orientation, gender identity, cultural/religious factors, interpreter use
- Trauma history, as disclosed
- Strengths and protective factors
Mental Status Examination:
- Behaviour: Describe client’s activity level and notable behaviours.
- Speech: Comment if speech was unusually fast or slow.
- Mood: Record client’s reported emotional state.
- Affect: Describe client’s emotional expression and range.
- Thoughts: Note thought processes and content, including any abnormalities.
- Perceptions: Record any hallucinations or sensory issues.
- Cognition: Describe memory, orientation, concentration, comprehension.
- Insight: Comment on client’s understanding of their condition.
- Judgment: Describe client’s decision-making ability.
Medical Assessment and Physical Examination:
- Physical examination performed and findings, including vitals/weight/BMI where taken; if none performed, state this explicitly and give the reason
- Neurological and movement assessment, e.g. AIMS
- Practitioner’s interpretation of medical contributors to the presentation
Laboratory and Diagnostic Studies:
- Studies reviewed, with dates and results
- Studies ordered this encounter and the clinical reason for each
Rating Scales and Psychometric Results:
- Each instrument administered/reviewed, date, raw score, subscale scores, as stated
- Practitioner’s stated interpretation, severity band and how it informs diagnosis/plan
Risk Assessment:
- Suicidal ideation — presence, frequency, intensity, duration, intent, plan, means access, preparatory behaviour, deterrents, instrument used
- Homicidal ideation and risk to others
- Self-harm, current and historical
- Access to lethal means and any steps to reduce access
- Violence and aggression history
- Risk formulation and management — overall formulation and specific steps taken (safety planning, means restriction, level-of-care decision, follow-up interval, crisis instructions, collateral involvement)
Diagnostic Formulation:
- Diagnoses with ICD-10-CM codes, specifiers, severity/course qualifiers, in priority order
- Supporting criteria and duration criterion for each primary diagnosis
- Differential diagnosis and rule-outs, with reasoning
- Medical and substance-related contributors excluded or pending
- Other relevant factors (e.g. Z codes for housing, occupational, relational problems)
Case Formulation:
- Integrated biopsychosocial formulation — predisposing, precipitating, perpetuating, protective factors
- Current functional status against baseline
Medical Decision Making and Medication Plan:
- Clinical reasoning for the treatment decision, options considered
- Medications started/changed/continued/discontinued — name, dose, route, frequency, quantity, titration
- Informed consent for medication
- Controlled substances and PDMP check
- Monitoring plan — metabolic, cardiac, hepatic, renal, drug levels, movement disorder screening, with intervals
- Non-pharmacological recommendations — therapy referral, behavioural recommendations, psychoeducation, safety planning
Problem List and Initial Treatment Plan:
- Numbered list: each problem, the initial objective, the planned intervention, and how progress will be measured (including named rating scale)
Level of Care and Disposition:
- Recommended level of care and reasoning
- Referrals and coordination, records requested, consent for coordination
- Medical necessity rationale
Interactive Complexity:
- Describe any specific communication factor that complicated the evaluation — third-party involvement, caregiver management, mandated reporting, communication barriers
Follow-Up:
- Next appointment — date, time, type, with whom
- Between-visit instructions, including worsening-symptom guidance and crisis resources given
- Pending items and who is responsible for each
Evaluation Summary:
- Summarise reason for evaluation, principal findings, diagnostic conclusion and basis, risk formulation, treatment initiated, disposition
Example Output
Encounter Details:
- Date of service: 3 September 2026
- Setting/modality: In person
- Evaluating practitioner: Dr Novo Psych, Psychiatrist
- Informants and records reviewed: Patient self-report only. Referral letter from primary care physician (PCP) Dr Novo Note reviewed.
- Consent and confidentiality: Verbal informed consent obtained for the evaluation and for information sharing with the referring PCP
Reason for Evaluation:
- Referral source and referral question: Referred by PCP Dr Novo Note for psychiatric assessment and management of low mood and anxiety not responding to lifestyle measures
- Chief complaint: “I’ve been feeling flat and on edge for months and I can’t shake it.”
History of Present Illness:
- Reports a six-month history of low mood, anhedonia and generalised worry, gradually worsening
- Symptoms occur most days; worry described as a constant “background hum” with intermittent escalation
- Precipitant identified as increased workload following a promotion in March 2026
- No clear alleviating factors identified; symptoms worsen with poor sleep and approaching work deadlines
- Neurovegetative symptoms: initial insomnia (up to 90 minutes to fall asleep most nights), reduced appetite with 3kg weight loss over two months, low energy, difficulty concentrating at work, no change in libido reported
- Functional impact: increased errors and reduced productivity at work, withdrawal from usual social activities, partner has noticed increased irritability at home
Past Psychiatric History:
- Prior diagnoses: One episode of major depressive disorder, diagnosed by PCP at age 24
- Prior treatment: No prior psychological therapy
- Medication trials: Sertraline 50mg for approximately eight months at age 24, described as “worked well,” discontinued by mutual agreement once well; no side effects reported
- Hospitalisations and higher levels of care: None reported
- Prior suicide attempts and self-harm: Denies any prior suicide attempts or self-harm
- ECT, TMS, ketamine or other interventional treatments: Not mentioned
Substance Use History:
- Alcohol: 4–6 standard drinks per week, social context only, no change in pattern reported, denies morning drinking or withdrawal symptoms
- Tobacco/nicotine, cannabis, stimulants, opioids, sedatives, hallucinogens: Denies current or past use of all listed substances
- Screening: No screening tools administered this encounter
Medical History:
- Current medical conditions: Hypothyroidism, diagnosed 2023, managed by PCP, currently stable on levothyroxine
- Past medical and surgical history: Nil reported
- Current medications: Levothyroxine 75mcg daily (PCP), oral contraceptive pill (PCP); denies use of supplements or over-the-counter medications
- Allergies and adverse drug reactions: NKDA
- Relevant medical review of systems: Denies palpitations, tremor or heat intolerance; denies recent changes in menstrual cycle
- Pregnancy, lactation and contraception status: Not currently pregnant; using oral contraceptive pill, no current plans for pregnancy
Family History:
- Mother has a history of generalised anxiety disorder, managed with escitalopram with good response
- No family history of suicide or substance use disorder reported
Social, Developmental and Cultural History:
- Current living situation and supports: Lives with partner of six years; describes relationship as supportive
- Education and occupation: Works full-time as a primary school teacher; recently promoted to a leadership role in March 2026, associated with increased workload
- Social determinants of health: No housing, financial or transport barriers reported
- Cultural, linguistic and identity considerations: English speaking, no interpreter required; no specific cultural or religious factors raised as relevant to care
- Strengths and protective factors: Strong relationship with partner, close friendship group, previously enjoyed running as a coping strategy but has stopped in recent months
Mental Status Examination:
- Appearance: Casually dressed, appropriate grooming
- Behaviour and psychomotor activity: Cooperative, appropriate eye contact, mild psychomotor slowing observed
- Mood: “Flat and on edge”
- Affect: Restricted range, mood-congruent, reactive to humour during rapport-building
- Thought process: Linear and goal-directed
- Thought content: No delusions, no ideas of reference; preoccupation with work performance
- Perception: No hallucinations, illusions, depersonalisation or derealisation reported
- Cognition: Alert and oriented to time, place and person; attention and concentration grossly intact on interview
- Insight: Good — recognises symptoms as significant and is seeking treatment
- Judgment: Intact — has continued to attend work and maintain safety
Medical Assessment and Physical Examination:
- Physical examination: No physical examination performed this encounter; assessment based on clinical interview, with recent physical review noted in PCP referral letter
- Medical interpretation: Hypothyroidism is stable on current treatment per PCP referral and considered an unlikely primary contributor to current symptoms; no evidence of another medical or substance-induced cause identified on interview
Laboratory and Diagnostic Studies:
- Studies reviewed: TSH reviewed by PCP in July 2026, within normal range on current levothyroxine dose
- Studies ordered: Repeat TSH and full blood count to reconfirm euthyroid status and exclude anaemia as a contributor to fatigue
Rating Scales and Psychometric Results:
- PHQ-9 administered today: total score 16 (moderately severe range)
- GAD-7 administered today: total score 14 (moderate range)
- Scores are consistent with the clinical presentation of moderate-to-moderately-severe depressive and anxiety symptoms and will be used to track treatment response
Risk Assessment:
- Suicidal ideation: Denies current suicidal ideation, intent or plan; no prior attempts
- Homicidal ideation and risk to others: Denies any current or past homicidal ideation
- Self-harm: Denies current or historical non-suicidal self-injury
- Access to lethal means: No firearms in the home; medications stored safely, denies stockpiling
- Violence and aggression history: Denies any history of violence or aggression
- Risk formulation and management: Overall risk assessed as low. No safety plan required at this stage; provided with crisis line information and advised to contact the practice or present to emergency department if symptoms of risk emerge before review
Diagnostic Formulation:
- Diagnoses:
- Major depressive disorder, single episode, moderate (F32.1)
- Generalised anxiety disorder (F41.1)
- Supporting criteria: Meets criteria for major depressive disorder with depressed mood, anhedonia, sleep disturbance, appetite change with weight loss, fatigue and concentration difficulty present for six months, causing clear functional impairment. Excessive, difficult-to-control worry present for a comparable duration, associated with fatigue and concentration difficulty, supports the generalised anxiety disorder diagnosis.
- Differential diagnosis and rule-outs: Adjustment disorder considered given the identifiable work stressor but excluded due to symptom severity, duration and the presence of a full depressive syndrome
- Medical and substance-related contributors excluded or pending: Hypothyroidism considered and judged unlikely to be the primary driver given stable thyroid function on treatment; repeat bloods ordered to confirm
- Other factors: Z56.6 — other physical and mental strain related to work
Case Formulation:
- Predisposing factors include a family history of anxiety and a prior depressive episode. The current episode was precipitated by increased workload and role change in March 2026. Perpetuating factors include ongoing high work demands, reduced sleep and withdrawal from previously protective activity (running). Protective factors include a supportive partner, established friendship network and good treatment engagement, all of which support a favourable prognosis with treatment.
- Functional status: Currently maintaining work attendance but with reduced performance; social withdrawal noted relative to baseline functioning six months ago
Medical Decision Making and Medication Plan:
- Clinical reasoning: Given a clear prior positive response to sertraline and current moderate-to-moderately-severe symptoms, pharmacological treatment alongside psychological therapy was recommended and accepted
- Medications started: Sertraline 25mg daily for one week, then increase to 50mg daily
- Informed consent for medication: Discussed common side effects (nausea, initial sleep disturbance, sexual side effects), the two-to-four week expected onset of benefit, and the need to seek review if worsening mood or new suicidal thoughts occur; patient verbalised understanding and agreed to proceed
- Monitoring plan: Review in two weeks to assess tolerability, then four-weekly thereafter; repeat TSH and full blood count as above
- Non-pharmacological recommendations: Referral to a psychologist for cognitive behavioural therapy; encouraged to reintroduce regular exercise as a behavioural activation strategy
Problem List and Initial Treatment Plan:
- Major depressive disorder, moderate — objective: reduce PHQ-9 score by 50% within 8 weeks; intervention: sertraline titration and CBT referral; measured via PHQ-9 at each review
- Generalised anxiety disorder — objective: reduce GAD-7 score to mild range within 8 weeks; intervention: sertraline and CBT referral; measured via GAD-7 at each review
- Sleep disturbance — objective: improve sleep onset latency; intervention: sleep hygiene education, review with medication response; measured via patient report at each review
Level of Care and Disposition:
- Recommended level of care: Outpatient management is appropriate; no indication for a higher level of care at this time
- Referrals and coordination: Referral to a psychologist for CBT; PCP to be updated with a summary letter and copy of psychometric results
- Medical necessity: Ongoing psychiatric management is medically necessary given moderate-to-moderately-severe symptom burden, functional impairment and the need for medication initiation and monitoring
Follow-Up:
- Next appointment: Review in two weeks with Dr Novo Psych to assess medication tolerability
- Between-visit instructions: Advised to contact the practice if symptoms worsen, new suicidal thoughts emerge, or significant side effects occur; provided with 988 Suicide & Crisis Lifeline details (call or text 988)
- Pending items: Repeat TSH and full blood count (patient to arrange); psychology referral letter to be sent this week
Evaluation Summary
Mary Blogs, a 34-year-old teacher, presented for psychiatric evaluation following PCP referral for a six-month history of depressive and anxiety symptoms precipitated by increased work demands. Assessment identified major depressive disorder, moderate, and generalised anxiety disorder, supported by PHQ-9 and GAD-7 scores in the moderate-to-moderately-severe range, with hypothyroidism considered and judged unlikely to be contributory pending repeat bloods. Risk was assessed as low, with no suicidal or homicidal ideation and no history of self-harm. Sertraline was recommenced with a titration plan, alongside referral for CBT and behavioural activation advice, with review in two weeks and ongoing outpatient management as the appropriate level of care.
- Template Type
- Assessment Session
- Session Note
Author:
Dr Ben Buchanan
NovoPsych CEO & Clinical Psychologist
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