Orient to the encounter
Confirm the setting, reason for contact, available time, participants, and whether the visit is routine, urgent, initial, or follow-up.
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Metropolitan General Health System
PMHNP Clinical Learning Environment
Clinical Preparation Resource
Preparing for the encounter
A brief, deliberate pre-encounter review helps you recognize urgent concerns, use the available record efficiently, and begin with a focused plan that can change as the patient's story emerges.
Review what is already known
Scan the referral, recent notes, diagnoses, medications, allergies, vital signs, laboratory findings, prior treatment, and documented safety concerns.
Identify immediate priorities
Look first for information that could change urgency, level of care, medical evaluation needs, medication safety, or the structure of the interview.
Prepare focused questions
Translate gaps, inconsistencies, and unresolved concerns into questions while preserving room for the patient’s own account.
Quick chart review
Know where to look—and what you are looking for
Not every chart contains every category. Use what is available, identify what remains unclear, and prioritize information that may affect safety or the direction of the encounter.
Referral or presenting concern
Why is the patient being seen now, and who initiated the contact?
Recent clinical documentation
What has changed, and are there conflicting or incomplete accounts?
Medication and allergy record
What is prescribed, what is actually taken, and what requires clarification?
Vitals, labs, and diagnostics
Are there abnormalities, trends, pending results, or medical contributors?
Risk and level-of-care indicators
Is there evidence of acute safety concern, impairment, intoxication, withdrawal, or inability to care for self?
Context and care coordination
What collateral, cultural, developmental, social, or team information may affect the encounter?
Before you begin
Create a short working plan
Keep the plan brief enough to use during the encounter and flexible enough to revise when new information emerges.
- The primary purpose of the encounter
- Immediate safety or medical priorities
- Key information gaps to clarify
- Likely collateral or coordination needs
- Treating the referral as a confirmed diagnosis
- Copying old information without verification
- Ignoring discrepancies between record sources
- Planning treatment before hearing the patient
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Integrated-care lens
Psychiatric preparation includes the whole clinical picture
Consider physical health, medications, sleep, nutrition, substances, reproductive factors, developmental history, culture, supports, and social conditions alongside psychiatric symptoms.