Like classical medicine, psychiatric science also has a large number of tools to carry out its purposes. One of the most important of these is the psychiatric medical record, which is designed to record the medical history under three main headings: the anamnesis, the patient's current condition and the treatment, if necessary, to be prescribed.

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That said, in this article we will talk about what a psychiatric medical record is, what its structure is and how to fill it out properly.

What is a psychiatric medical record

A psychiatric medical record is defined as a document where you can record a series of data concerning your patients. Its content is derived from the medical interrogation that you must carry out in order to evaluate their history, condition and possible ailments.

There are different models of psychiatric medical records that may vary according to their function. In fact, the most complete ones are usually used in specialists' offices and the more general ones are optimal for outpatient centers.

The content of a psychiatric medical record is usually written in handwriting on sheets of paper with a specific format to be filled in. However, recently, the use of management software with medical records that fulfill this purpose has become popular, as is the case of the one we offer at AgendaPro, which, if necessary, you can print either to keep a backup of your work or for legal matters.

Parts of a psychiatric medical record

As in other health care fields, the psychiatric medical record includes both general data and other specific data. Thanks to the recording of this information, these documents have gained ground and importance within the medical specialties. It has been shown that their use translates into the possibility of saving time and tabulating data according to the purposes of each process and investigation.

As already mentioned, the psychiatric clinical history is usually printed but you can also empty it in a specialized software for the PC. In any of the cases, visually it consists of a format of three differentiated and specific sections where the history of your patients should be reflected. A possible distribution would be as follows:

1. First section of a psychiatric medical record

The first section of the psychiatric medical record consists of the anamnesis. In this section, general identification data such as the history number, first and last name of the patient, date of birth, age, address, telephone number of the patient and a family member, and social security number are compiled. The following information is then recorded:

• Reason for consultation [MC] : The reason for the particular psychiatric consultation is recorded in this segment.
• History of the current illness [AEA]: The symptoms of the condition are detailed and its development is described chronologically. The possible causes to which the condition is attributed are also noted. It is also recorded if there are previous diagnoses or medications.
• Family history [FA] : In this section, data on the patient's family members are entered, such as: age of parents, number of siblings, current partner, age and sex of the partner, number of children, etc., in order to trace possible personal pathological history [PPA] of any psychiatric illness.
• Personal history [HP] : This section prioritizes questioning the patient about his or her personal life. Some relevant data in this section highlight childhood testimonies such as the type of breastfeeding, the age at which he/she acquired motor skills or if he/she practiced co-sleeping with his/her parents. It also inquires about aspects closer to adolescence such as sexual initiation, jobs, marital history, habits, etc.

2. Second section of a psychiatric medical history

The second section of the psychiatric history contains information concerning the patient's current status and psychiatric diagnosis.

• The current state : It should indicate the patient's level of consciousness (whether he is lucid or not, whether he is aware of the record) and also whether he is aware of his pathology and his situation. For this purpose, recognition factors such as global and self-psychic orientation (time, person and place), body and facial expression, psychic attitude (active or passive), gait and motor skills are taken into account. This section also includes specific data such as whether their activity range is normal, hyperactive or hypoactive and other basic medical data such as heart rate.
• The psychiatric diagnosis: After studying all the evidence provided by the patient and analyzing the physiological signs and symptoms, this is the ideal place to note, describe and explain the reasons for the possible psychiatric disorder. This section is vital because it is the basis for determining the treatment to be followed.

3. Third section of a psychiatric medical history

Finally, in the third section of the psychiatric medical record, the following should be recorded:

• The treatment that corresponds to the evolution : This section has a detailed record of the drugs to be administered for the purpose of monitoring their use, their effects and measuring the progress in tracing the goal of balancing the patient's mental health.

Psychiatric medical record: example

Let us now look at a standard format for this type of psychiatric medical record:

First section of a psychiatric medical record:

• Identification Sheet
  • • Full name: Maria Perez
    • Age: 25
    • Nationality: Spanish
    • Identification No.: XXX-XXX-XXX
    • Marital Status: Single
    • Place of residence: Mexico City
    • Medical history: No medical history
    • Family contact number: XXX-XXX-XXX-XXX
• Reason for consultation
  • • Description of illness: Violent behaviors.
    • Chronology of the condition: They refer loss of self several weeks ago. Patient lived in a street situation during that period.
• Family psychiatric history: Mother and sister with bipolar disorder.
• Consumption of narcotics: Yes.
• Previous treatments: Not indicated.
• Sexual behavior: No indication.
• Other physical conditions: Patient claims to have HIV.

Second section of a psychiatric medical history:

• Current status
  • • Psychophysical examination: Normal.
    • Psychomotor examination: Normal.
    • Psycholinguistic examination: Abnormal.
    • Psychomental examination: Alienated.
    • Evaluation of the condition: violent behavior, aggravated with signs of mental derangement.
• Psychiatric diagnosis
  • • Description of the disorder: Possible bipolar disorder. Withdrawal syndrome.
    • Tests to be performed: Next evaluation after detoxification process. One month.

Third section of a psychiatric medical history:

• Treatment
  • • Prescription: XXX, 50mg.
    • Dosage: Administer indicated dose every 8 hours.
    • Contraindications: Do not double dose. Do not substitute. Do not take other drugs.
• Other recommendations: Little or no contact with family and friends in the detoxification process is suggested.

Difference between medical history, psychological history and psychiatric medical history.

The three medical history formats share many similarities in structure. Basically, the anamnesis process is the same in all of them and only varies in the psychiatric clinical history due to some particularities regarding the description of the patient's pathology. A medical history takes into account a wider range of bodily ailments and a psychological history does not have the authority to prescribe medication.

In general, psychiatric medical records are specialized in the diagnosis of psychiatric conditions, therefore, they focus mainly on the diagnosis of the patient's state of consciousness and not necessarily on physical examinations. In conclusion, any medical chart format is adjustable to the nature of the medical branch in which it is applied.

Remember that you can have it in both printed and digital format, but from AgendaPro we recommend you to have a medical software with medical records, which will undoubtedly help you to safely store this type of information so important for your business and for your patients.

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