Overview

A psychiatric assessment is a medical process involving systematic gathering of information in order to arrive at an appropriate diagnosis. It has to be thorough and usually takes about 45 minutes – 1 hour. It can take longer for complex or uncooporative patients.

The history of the patient can also be gathered from others i.e. friends and relatives

History

Biodata

Diagnostic possibilities and etiological factors can be suggested from the biodata of the patient. The biodata also helps the clinician to understand the background, aspirations, resources, tasks faced and the social support likely to be available to the patient.

• Details about the patient (Mnemonic: NASRREMO)
  • Name
  • Age
  • Sex
  • Religion
  • Residency
  • Level of Education
  • Marital status
  • Occupation
• Details about the admission and interview
  • The source of referral (who referred or brought the patient to hospital?)
  • Cause of referral
  • Mode of admission (described in the mental health act)
  • Date of admission
  • Place of interview
  • Date of interview
  • Informant
  • Language of interview

Modes of admission

Mode of admission	Description
Voluntary admission	Referral may be made by a medical practitioner. Patients are reviewed within 72 hours by a psychiatrist and are detained for a period of no more than 42 days. Then they may be reviewed and involuntarily detained if warranted. The form filled on admission is the MOH 613
Involuntary admission	Referral is made by relatives, people connected to the patient, or a medical practitioners. The may be admitted for a period not exceeding 6 months, which can be further extended by 6 months through a renewal order. The total period should not be more than 12 months continuously.
Emergency admission	Referral is made by comissioned officers or chiefs when they deem the patient to be a danger to themselves or others. The patient should be taken to a mental hospital withn 24 hours of being taken into custody. They officer then goes through the procedure of an involuntary detention in an approved center and can be detained for 72 hours after initial examination.
Admission of foreign nationals	Approval of the admission is done by the foreign goverment or relevant authority through writing to the board. The patient should be examined after initially reporting wihtin 72 hours and should not be detained for more than 2 months
Admission of members of the armed forces	Referral is made by a clinician of the armed forces. Patients are detained for an initial period of not more than 28 days but can be extended after re-examination by a psychiatrist. If a member of the armed forces ceases to be a member while admitted they become can become an involuntary patient after the hospital is notified.
Admission through the criminal justice system

MOH Forms for admission into a mental health institution

Form	Details
MOH 613	Voluntary admission
MOH 614	Involuntary admission by source of referral
MOH 615	Involuntary admission recommended by a medical practitioner
MOH 637	Involuntary admission filled by parents or guardians for a patient < 16 years old

Presenting Complaint or Allegations

This is the complaint or allegations that have caused the patient to be referred to the mental health institution. It should be recorded in the patients own words and is further expounded on in the history of the presenting complaint.

Ask the patient: Why do you think you are here?

• Examples of presenting complaints in depression
  • “Feeling sad”
  • “Feeling tired all the time”
  • “Cannot enjoy anything”
  • “Want to die”
  • Other non-specific somatic complaints
• Examples of presenting complaints in schizophrenia
  • “Hearing voices”
  • “My life is at risk’
  • “My work colleague has put an evil spell on me”
  • From a relative of a patient who is oblivious of their condition: “He/she has gradually deteriorated over the last 1 year”

History of the Presenting Complaint

Chronological Sequence of how the symptoms appeared. As much information is gathered using both open-ended and direct questions.

• Some questios to ask in the presenting complaint
  • When did the symptoms start and how long have they been present?
  • What caused the symptoms to start, or is there any significant event that happened leading up to the symptoms? (for precipitating factors e.g. stressful life event, non-compliance with medication)
  • Is there anything making the symptoms worse?
  • How do these symptoms affect your day to day life? (impact of functioning in self-care, school, family, or work)
  • Have these symptoms changed over time?

Psychiatric Review of Symptoms

The psychiatric review of symptoms involves asking screening questions for common psychiatric conditions. It may reveal symptoms that might not have showed up in the history of the presenting complaint since some of these symptoms may be egosyntonic and the patient may regard them as being “normal”.

It is important to ask about any mood symptoms (SIGECAPS for depression or DIGFAST for mania), anxiety symptoms (from generalised anxiety symptoms, OCD, PTSD, phobias etc.), psychotic symptoms (hallucinations, delusions, paranoia), and other symptoms of psychiatric illnesses such as ADHD or eating disorders.

Some of the following questions should be asked of most (if not all) patients presenting for psychiatric assessment.

• Questions about mood
  • How have you been feeling lately? How long have you felt this way?
  • Tell me about your hobbies and interests? Do you still enjoy doing those things (Anhedonia)
  • Do you spend a lot of time blaming yourself for things you have done wrong? (Guilt)
  • Do you tend to look at things with a positive or negative state of mind? (Attitude/pessimism)
  • Have you had any changes in appetite? If so have how much weight have you gained or lost?
  • Have you had any changes in sleep? Have you had difficulty getting off to sleep (initial insomnia), waking up in the middle of the night (middle insomnia), or waking up more than two hours earlier than usual then being unable to get back to sleep (early morning waking is common in depression)? Do you feel like you wake up feeling unfreshed or sleep excessively?
  • Have you had any changes in energy? Has it increased or decreased?
  • Do you have a heightened sense of self importance or spirituality (closer to God)?
  • Have you had sensations of thinking being more difficult, slower or mixed-up, or being faster, easier and more efficient?
• Questions about psychosis
  • Have you ever heard or seen things that others cannot? (Hallucination)
  • Have you heard voices talking to you only when nobody else is around? (Hallucination)
  • Have you ever feared that someone was trying to harm you or that there was a plot against you? (Delusions)
  • Have you ever felt you were receiving special messages from the TV, radio or internet?
• Questions about memory
  • How is your concentrating and memory?
  • Do you have difficulty reading or following a conversation?
  • Do you feel like you are frequently forgetting things?
• Questions about stressors and support?
  • Is there anything in your life that has been difficult to cope with?
  • Do you feel like you have anyone to talk to when you feel this way?
  • Have you had any difficult or traumatic events recently?
  • Were you ever physically, sexually or emotionaly abused?
  • Have you ever experienced an extremely traumatic event, which you currently continue to re-experience in the form of flashbacks or nightmares?
• Questions for risk assessment
  • Have you ever considered hurting yourself or others?
  • Have you ever considered ending your life?
  • Do you have any plans regarding ending your life?
  • Have you ever attempted to harm or kill yourself?
  • Do you have any pills or guns at home?
  • Do you feel safe in your relationship? (intimate partner violence)
  • Do you have a safe place to go when you feel threatened?
• Mnemonic: DIG FAST for mania
  • Distractibility
  • Irritability
  • Grandiosity
  • Flight of ideas
  • Activity increase
  • Sleep (decreased need of)
  • Talkativeness
• Mnemonic: SIG E CAPS for depression
  • Sleep
  • Interest
  • Guilt
  • Energy
  • Concentration
  • Appetite
  • Psychomotor agitation/retardation
  • Suicidal ideation
• Types of suicidal ideation
  • Fleeting ideas
  • Persistent ideas
  • Clear suicidal plan
  • Actual suicidal attempt

Past Psychiatric History

This is a chronological order of past episodes. It may give important information about what the current episode might be. Major mental illnesses like depression and schizophrenia follow a chronic course with relapses and remissions.

• Past psychiatric history
  • Previous episodes, hospitalisations, treatment and diagnosis
  • Compliance to treatment and follow-up
  • Previous suicidal attempts

Medical Review of Systems

Ask the patient about any systemic symptoms. It is important to consider whether any symptoms point to an organic disease that is manifesting with psychiatric symptoms or vice versa. Neurological symptoms are always reported.

Past Medical and Surgical History

• Questions to ask in the medical history
  • Medical illnesses that the patient suffers from
  • Medication that the patient is on
  • Significant past illnesses, injuries, surgeries
  • Any illness/injury that may have impaired the patient’s development (either by reducing opportunities or by directly affecting brain function)
  • Any drug allergies
• Examples of relevant medical history
  • Hypothyroidism can mimic symptoms of depresion
  • Hyperthyroidism can mimic symptoms of anxiety
  • Steroids can cause mood changes and psychotic symptoms
  • Drug interactions
  • Hepatic or renal impairment requires lower doses of medication (therapeutic doses may become toxic)
  • Certain drugs are avoided in pregnant patients e.g. Lithium, valproate
• Factors contributing to poorer physical health and lower life expectancy in patients with mental illness
  • Lack of motivation to see a doctor for physical symptoms when needed
  • Unhealthy lifestyle such as smoking and lack of exercise are more common in the mentally ill
  • Poor compliance with treatment for both phsyical and mental illness
  • Patients may not be able to coherently explain their physical symptoms which causes some important diagnosis and treatment to be overlooked
  • Physicians may not treat physical illness in the mentally ill properly (may ignore or dismiss physical symptoms as being psychological)
  • Some medication used to treat psychiatric disorders have side effects e.g. obesity, diabetes, hyperlipidaemia and parkinsonism

Personal History

• Significance of personal history
  • Obstetric complications and pre-mature deliveries are associated with increased risk of future mental disorder
  • Early adverse experiences e.g. neglect, physical/emotional abuse, poverty etc. are risk factors for future mental illnesses, especially depression
  • Significant social decline e.g. high achievement at school followed by dropping out of college suggests a chronic disorder like schizophrenia
  • Personal habits e.g. alcohol and drugs can cause or complicate the course of mental illness and interact with psychotropic medication
  • Difficult interpersonal relationships can be an indicator of a personality disorder
  • Frequent problems with the law e.g. drunk driving and violence towards others with the patient unwilling to take respoonsibility can suggest antisocial personality
• Questins to ask in the birth history
  • Include events from the time before birth which may be relevant to personal history for example: unwanted pregnancy, father absent at time of birth, maternal substance use or illness during pregnancy, etc.
  • Also include the manner of birth (vaginal or caesarean) including any complications
• Questions to ask in the childhood history (early life experiences)
  • Early development and achievement of milestones: including age at which the patient first spoke and walked, comparisons with siblings and any evidence of delays or precocity
  • Who raised the patient?
  • How would the patient describe the family life of his or her early years – warm, frightening, etc.
• Questions to ask in the education history
  • How did you perform scholastically (“in lessons and tests”)? A history of having found these difficult may suggest intellectual disability, or a severely disorganized home life. Good performance in primary school followed by poor performance in secondary school suggests an inability to comply and delay gratification which may indicate an emerging personality disorder; alternatively, and less commonly, an prodromal psychosis.
  • How did you get along with the other students? A history of few friends or being very socially isolated suggests avoidant or schizoid traits or prodromal psychosis. A history of being ‘popular’ and frequent falling out (“fights”) suggests emerging Cluster B personality disorder. A history of few friends but above average school performance suggests obsessional traits.
  • How did you get along with the teachers? Shyness of primary school teachers may predict an anxiety disorder or Cluster C (anxious/fearful) personality traits. Teachers symbolize authority. Conflict with teachers often emerges in secondary school (although in pronounced cases it may be present in primary school) suggest the individual may not comply with the rules of society, in adult years.
  • Was the individual involved in other school activities? Some young people have as little to do with school as possible. Others engage in choirs, sporting and similar activities both in and outside school hours. Such engagement suggests ability to delay gratification and derive pleasure from social interaction; and in the case of sport, some confidence in physical ability.
• Questions to ask in the employment history (social circumstances):
  • The type of work pursued
  • The dates of employment (starting and leaving): give the length of any periods of unemployment.
  • The reason for leaving each employer, and whether there was difficulty in finding the next position.
  • Inability to provide details with a relative ease suggests cognitive difficulties, secretiveness (may be paranoid or deceptive in origin), or that employment was only fleeting.
• Questions to ask in the marital and relationship history
  • Length of each relationship, as well as the reasons why they ended if they did
  • Relationship between the patient and their partner
  • Children or dependents of the patinet
• Questions to ask in the sexual history
  • Sexual debut: age, with whom, consensual vs non-consensual?
  • Sexual orientation: Heterosexual, MSM, WSW
  • Number of sexual partners
  • History of treatment for STIs
  • Paraphilias
  • Masturbation (worries, guilt, fantasies, deviation, dysfunction)
• Questions to ask in the menstrual history
  • Menarche
  • Cycle length, regularity, quantity
  • Cycle abnormalities (dysmenorrhoea, amenorrhoea, AUB)
  • Menopause (if relevant)
• Questions to ask in the drug and substance history
  • Name of drug
  • When they first started using it and why?
  • Quantification
    • Rolls of cannabis
    • Pack years of cigarettes
    • Units of alcohol
    • Grams of cocaine
    • Kilograms of khat
  • Always rule out the possibility of substance use disorder in a patient presenting with a history of drug use
    • Frequency of use (daily, weekends, few days of the week)
    • Cravings
    • Risky behavior from use of the substance
    • Social impairment from use of the substance
    • Withdrawal symptoms and tolerance
• Questions to ask in the patient’s forensic history
  • Violence/aggression
  • Trouble with police
  • Theft
  • Arrests
  • Convictions
  • Imprisonment
• Questions to help establish a patient’s pre-morbid personality
  • Ask a close relative or friend who has known the patient for many years to describe them in 2 or 3 words. They may be described as “extrovert”, “shy”, “anxious”, “impulsive”, “suspicious”, “eccentric”, “attention-seekng”, “friendly”, “perfectionist”, “reliable”
  • Ask about hobbies and interests and if there is any change in their level of enjoyment: gives an idea of whether the patient is an introvert or an extrovert, and if there is a decrease in interest it can indicate anhedonia
  • Size of the social circle: a good social network can be a protective factor against some psychiatric disorders such as depression
  • Religious or spiritual beliefs if appropriate: can be a source of support for the patient or if a previously non-religious patient suddenly becomes overeligious it could point towards a mood disorder such as mania
  • Response to stress: whether the patient is able to deal independently and effectively, whether they are dependent on others, tendency to abuse alcohol or resorting to self-harm
• Questions to ask about the patient’s current living situation
  • Who does the patient live with?
  • Where do they live?
  • What is their financial situation?

Family History

Major mental illnesses have a strong genetic component. Having a biological relative with a mental illness increases one’s risk of suffering from that illness.

‘Vulnerability-stress’ model

Vulnerability (genetic loading)	Stress needed to become ill
Low vulnerability	High stress
Medium vulnerability	Moderate stress
High vulnerability	Low stress

• Questions to ask in family history:
  • Who raised the patient?
  • Was there an adult of both sexes in the home?
  • Were either of the parents away from the home for long periods?
  • Were either, neither or both parents emotionally close to the patient?
  • How many children were there in the family and what were their names?
  • Where did the patient come in the sib-ship and what were the age differences?
  • With which siblings did the patient have the closest emotional relationship?
  • How would the patient describe each parent figure?
  • How would the patient describe the family life of his or her early years – warm, frightening, etc.
  • Were any other significant adults present during development?
  • Any known family medical or psychiatric disorders? Time spent in a psychiatric hospital, suicide, substance use and convictions, etc.
  • Ask about any family history of suicide (risk factor for suicide)

Mental State Exam

Appearance and Behavior

Think of apperance as a written account of a still photograph, written for someone who cannot see it.

Think of behavior as a writtent account of a video.

• Assessment of appearance
  • Estimated age by physical appearance and whether there is a difference in apparent vs. stated age
  • Body habitus: stature, body weight/nutritional status, physical abnormalities (buffalo hump, etc)
  • Dressing: type of clothing, amount of clothing, is the clothing appropriate?
  • Hygiene: level of grooming, presence of body odor and/or halitosis
  • Distinguishing features: tattoos, body piercings, dental braces, jewellery , wounds (burns scratches, needle marks) and scars (previous self-harm)
  • Evidence of substance misuse: injection tracks for IV drug use, Spider naevi and jaundice in alcoholic liver disease due to alcohol
  • Stigmata of disease such as exophthalmos (thyroid), buffalo hump (cushing’s), jaundice (liver disease)
  • Objects the patient has or is carrying
  • Posture
• Assessment of behavior
  • Level of eye contact: none, decreased, normal or increased
  • Type of eye contact: fleeting or intrusive
  • Attitude towards interviewer: friendly, cooperative, indifferent, seductive, defensive, playful, guarded, evasive
  • Compulsions: Stereotyped action that the patient cannot resist performing repeatedly (usually follows an obsession)
  • Disinhibition: Loss of control over normal social behavior
  • Posturing: Maintenance of bizarre gait or limb position for no valid reason
  • Distractibility
  • Body language and Gestures
  • Psychomotor activity: including psychomotor agitation, restlessness or psychomotor retardation
  • Abnormal motor activities: mannerisms, stereotypies, tics, echopraxia, bradykinesia and hypokinesia
  • Abnormal postures: including mitmachen and mitgehen
  • Amotivation: including apathy, abulia and akinetic mutism
• Example: Description of appearance and behavior for a healthy patient or a patient in remission
  • Appropriately dressed
  • Cooperative
  • Maintained good eye contact
  • Established a good rapport
  • No prominent psychomotor agitation or retardation
• Example: Description of appearance and behavior for an acutely psychotic patients
  • Highly agitated
  • Uncooperative
  • Suspicious
  • Intense eye contact
• Example: Description of appearance and behavior for a severely depressed patient
  • Withdrawn
  • Reduced facial expressions
  • No eye contact
• Example: Description of appearance and behavior for a catatonic patient, in stupor
  • Motionless and mute

Speech

• Assessment of speech
  • Spontaneous vs latent speech
  • Volume: loud, normal, soft, whispering, or shouting
  • Rate: rapid, pressured, normal, or slow
  • Quantity: talkative, logorrhoeic, poverty of speech, mutism or garrulousness
  • Abnormal language: neologisms, dysphagia or clanging
  • Tone and quality of speech: accent and emotionality
  • Articulation and fluency: incomprehensible, stuttered lisping, mumbled, slurred, clear, stammering or dysarthria
  • Content of speech: word salad, neologisms, perseveration, echolalia, palilalia, clang association, alexythymia
• Example: Description of speech in a healthy patient or a patient in remission
  • Speech was normal in rate, rhythma and volume
  • No evidence of any formal thought disorder
• Example: Description of speech in a patient with schizophrenia
  • Disjointed
  • Irrelevant speech that does not make much sense
• Example: Description of speech in a patient with Depression
  • Speaks in a low volume voice, slowly, and with long pauses

Mood and Affect

Mood is a pervasive and sustained emotion or feeling that influences a person’s behavior and colors his or her perception of the world. Usually described in the patient’s own words.

Affect is the pattern of observable behaviors that is the expression of a subjectively experienced feeling state (emotion) and is variable over time, in response to changing emotional states

• Assessment of mood and affect
  • Mood is subjective and is what the patient reports
  • It can be described as being sad, afraid, over-the-moon, irritable, depressed, euphoric, euthymic etc.
• Assessment of affect
  • Affect is objective and is what the psychiatrist observes
  • Quality: irritable, anxious, sad, euphoric
  • Congruency: mood congruent, mood incongruent
  • Range: full, flat , blunted, exaggerated
  • Mobility: fixed, labile, constricted
  • Appropriateness: appropriate, inappropriate
• Example: Description of mood and affect in a healthy patient or a patient in remission
  • Subjectively the patient reported a stable mood
  • Objectively the patient has a reactive and euthymic affect

Thought

• Assessment of thought
  • If abnormal, give a description of the abnormalities
  • Thought form: how the patient uses language and puts ideas together. Includes circumstantiality, tangentiality and thought block
  • Thought process: how ideas are expressed by the patient. This is usually described under speech. It includes loosening of association, flight of ideas, derailment, irrelevant answers, claning, perserveration, word salad and neologisms
  • Though content: includes delusions, overvalued ideas, obsessions and suicidal or homicidal ideation
  • Though possession: passivity phenomena related to thought e.g. thought insertion or thought withdrawal
• Example: Description of thoughts in a healthy patient or a patient in remission
  • The patient does not have any disorders of thought process or possession (control)
  • The patient did not report any delusions, overvalued ideas, obsessions, suicidal or homicidal ideation

Perception

• Assessment of perception
  • Hallucinaitons in any of the sensory modalities
  • Sensory distortions
  • Illusions
  • Depersonalisation and derealization
• Example: Description of perception in a healthy patient or a patient in remission
  • The patient did not report any hallucinations in any of the sensory modialities
• Example: Description of abnormal perception
  • The patient is hearing 3rd person voices of his dead parents making derogatory remarks of him

Cognition

• Assessment of cognition
  • Consciousness: using the glasgow coma scale (GCS)
  • Orientation to time, place and person: Ask the year, month, day and time (+/- 2 hours is acceptable), ask where they are, and ask if they can identify health workers and fellow patients.
  • Attention: Give the patient 3 unrelated objects and ask them to repeat it immediately
  • Concentration: Ability to sustain focus. Can be tested using serial 7s, serial 3s, WORLD spelt backwards, months of the year backwards or days of the week backwords. Failed if the patient takes too long (> 3 seconds) to answer
  • Registration (immediate recal): tested the same as attention
  • Short-term memory: Ask the patient what they ate for supper or lunch the previous day and corroborate it
  • Long-term memory: Ask the patient to recall important event in their life. This can be corroborated if need be
  • Abstract thinking: ask the patient to interpret a proverb in their own words, ask the to group objects, or ask them similarities and differences e.g. ‘What is the similarity and difference between a watch and a ruler”
  • Fund of knowledge: assess by asking the patient to name the presidents or the year of independence of their country
  • Judgement: give the patient a hypothetical situation relevant to their illness. Do not present them with a dilemma.
• Abnormalities of cognition
  • Orientation is impaired in acute confusional states e.g. delirium
  • Concentration is impaired in severe psychosis and depression
  • Memory is impaired in dementia (an MMSE is usually done to quantify the cognitive deficit if dementia is suspected)

Insight

Insight is defined as the awareness shown by the patient into the nature of his/her difficulties. An acutely ill patient might lack insight and might be admitted against their will. A stable patient may show full insight.

Levels of Insight

Level of insight	Description
Level I	Complete denial of illness
Level II	Slight awareness of illness; denies needing help
Level III	The patient has awareness of illness; but blames it on external or organic factors
Level IV	Awareness of illness; but the cause is unknown to the patient
Level V	Intellectual insight. The patient has awareness of their illness; knows the cause of the illness; knows what should be done; but does not take the necessary steps to achieve recovery
Level VI	True emotional insight. Emotional awareness of the motives and feelings within themselves; important persons in their life leads to basic changes in behaviour

• Requirements for a good insight
  • Patient agrees that he/she has mental illness
  • Patient acknowledges the need for treatment
  • Patient complies with the prescribed treatment

Case Formulation

Summarise the key-aspects of the case using the Bio-Psycho-Social approach. Identify potential biological (e.g. family history), psychological (e.g. personality) and social (e.g. adverse life circumstances) that may play a role as predisposing. Not all patients may have all these factors. The factors may also not be purely biological, psychological or social and may cut across. Also assess for and comment on risk to self (e.g. suicide), risk to others (e.g. psychotic patients with voices commanding them to harm others), or risk of being abused or exploited by others (e.g. dementia).

Biopsychosocial model

	Biological	Psychological	Social
Predisposing	Family history (Genetic risk)	Childhood loss of a parent	Poverty
Precipitating	Non-compliance with medication	Relationship breakdown	Sudden loss of a job
Maintaining	Abuse of cannabis	Maladaptive personality traits	Violent unsupportive partner

• Precipitating factors
  • Drug/substance related
  • Psychosocial stressors
  • Loss of job
  • Loss of family member
  • Loss of spouse/partner
  • Medical illness
  • Rape
  • Abuse
• Predisposing factors
  • Biological
  • Genetics (Family history)
  • Medical condition (Traumatic brain injury, hyperlipidemia, hypothyroidism, pregnancy)
  • Psychosocial factors
  • Early parental loss
  • Parental divorce
  • Unstable family life
  • Childhood trauma (abuse, rape, neglect)
• Perpetuating factors
  • Biological
  • Psychosocial
  • Ongoing drug/substance abuse
  • Financial difficulties
  • Ongoing poor interpersonal relationships
  • Poor coping mechanisms
• Protective factors
  • Social support
  • Insight
  • Previous treatment response
  • Age at presentation
  • Absence of comorbidities
  • Good premorbid personality

Multi-Axial Diagnosis

Criteria for diagnosis can be described using the ICD-10 or DSM-V. The multi-axial diagnosis is described in the DSM-IV. Patients with a complex history may require more than one session to establish a diagnosis. If the diagnosis is not clear possible differentials need to be considered. Diagnostic co-morbidities also need to be considered e.g. PTSD + alcohol use disorder or schizophrenia + cannabis use disorder

Multi-axial diagnosis according to the DSM-IV

Axis	Description
Axis I	Psychiatric Disorder, with at least 3 differentials
Axis II	Personality Disorder
Axis III	General Medical Condition
Axis IV	Psychosocial stressors
Axis V	Global assessement of functioning

Investigations

List investigations in terms of biological, psychological and social investigations, justifying the reason for each.

Treatment plan

This should also be divided into biological, psychological and social interventions with reasons as to why it would be beneficial for the patient.

Prognosis

List the patient’s good and poor prognostic factors, with a final comment on whether the prognosis is overall good or poor.