Connect and orient
Introduce your role, confirm who is present, explain the purpose and limits of the encounter, and establish psychological and physical comfort.
M
Metropolitan General Health System
PMHNP Clinical Learning Environment
Assessment Resource
Psychiatric Interview & History
The psychiatric interview is both a clinical assessment and a therapeutic encounter. Use a flexible structure to understand the patient's experience, gather essential evidence, assess safety, and begin a collaborative working relationship.
Invite the patient’s story
Begin broadly. Ask what brought the patient in now, what feels most important, and what they hope will be different after the visit.
Clarify and organize
Develop the timeline, severity, functional effect, context, associated features, and relevant negatives without turning the conversation into a checklist.
Complete the clinical picture
Explore psychiatric, medical, developmental, family, social, cultural, trauma, substance, treatment, and medication history.
Synthesize and close
Summarize what you heard, check accuracy, address urgent concerns, invite questions, and explain what will happen next.
Core history
Build a whole-person clinical picture
Depth depends on the setting, urgency, developmental stage, patient capacity, and purpose of the encounter. Verify previously documented information rather than assuming it remains accurate.
Presenting concern and goals
Why now? What changed? Whose concern is it? What does the patient want help with?
History of present illness
Onset, course, triggers, severity, associated symptoms, prior episodes, function, coping, and relevant negatives.
Psychiatric history
Prior diagnoses, treatment settings, hospitalizations, crises, self-harm, violence, psychotherapy, and response to care.
Medication history
Current and prior medications, adherence, benefit, adverse effects, reasons stopped, access, and nonprescribed use.
Substance and caffeine use
Substance, amount, frequency, pattern, last use, consequences, tolerance, withdrawal, recovery efforts, and readiness for change.
Medical and neurologic history
Conditions, pain, sleep, reproductive factors, head injury, seizures, procedures, allergies, and possible medical contributors.
Family history
Psychiatric conditions, substance use, suicide, treatment response, medical conditions, relationships, and family understanding of symptoms.
Developmental and social history
Pregnancy and birth when relevant, milestones, education, work, relationships, living situation, legal history, military service, and supports.
Trauma and adverse experiences
Ask with permission, explain relevance, avoid unnecessary detail, assess current impact, and support choice and control.
Culture, identity, and context
Language, identity, beliefs, community, discrimination, spirituality, explanatory model, social conditions, and barriers to care.
From story to evidence
Move from open exploration to focused clarification
Broad questions reveal the patient's priorities and language. Focused questions then establish clinical detail, distinguish among explanations, and identify what requires action.
“Tell me what the last few weeks have been like for you.”
“When did you first notice a change? What was happening around then?”
“When you say anxious, what does that feel like in your body and thoughts?”
“How has this affected sleep, school or work, relationships, and daily responsibilities?”
Ask focused questions about associated symptoms, medical contributors, medications, substances, and relevant diagnostic exclusions.
“What do you think is happening, and what worries you most about it?”
Interview techniques
Keep the encounter clinically focused and human
- Open questions, reflection, clarification, and summaries
- Plain, neutral, nonstigmatizing language
- Permission before sensitive or trauma-related questions
- Specific behavioral examples instead of labels alone
- Silence and pacing that allow the patient to think
- Direct, calm questions about suicide, violence, and safety
- Rapid-fire questioning or abrupt topic changes
- Leading questions that imply the preferred answer
- Premature reassurance, interpretation, or diagnosis
- Jargon, stacked questions, and vague timeframes
- Accepting copied history without patient verification
- Avoiding difficult questions because they feel uncomfortable
+
Integrated-care lens
Psychiatric symptoms do not occur apart from the body or environment
Ask how physical health, medications, sleep, nutrition, pain, hormones, substances, cognition, trauma, culture, relationships, work, finances, housing, and access to care may contribute to the presentation or shape a realistic plan.