Psychiatric Certification Requirements
Core Assessment Requirements
- The American Psychiatric Association recommends a comprehensive psychiatric evaluation that includes specific assessment domains covering history of present illness, psychiatric history, substance use, medical history, family history, personal/social history, and mental status examination as requirements for proper psychiatric certification 1, 2, 3
- Assessment must include psychiatric review of systems, including anxiety symptoms and panic attacks 1
- Evaluation of past or current sleep abnormalities, including sleep apnea 1
- Assessment of impulsivity 1
- Documentation of past and current psychiatric diagnoses 2
- Assessment of prior psychotic or aggressive ideas, including thoughts of physical or sexual aggression or homicide 2
- Evaluation of prior aggressive behaviors (e.g., homicide, domestic violence, workplace violence) 2
- Assessment of prior suicidal ideas, suicide plans, and suicide attempts, including details of each attempt 2
- Documentation of prior intentional self-injury without suicidal intent 2
- History of psychiatric hospitalizations and emergency department visits for psychiatric issues 3
- Documentation of past psychiatric treatments (type, duration, and doses where applicable) 3
- Assessment of response to past psychiatric treatments 3
- Evaluation of adherence to past and current pharmacological and non-pharmacological treatments 3
Additional Required Domains
- Assessment of tobacco, alcohol, and other substance use 4
- Documentation of any misuse of prescribed or over-the-counter medications or supplements 4
- Evaluation of current or recent substance use disorders 4
- Documentation of allergies or drug sensitivities 5
- Assessment of all current and recent medications, including side effects 5
- Evaluation of relationship with primary care provider 5
- Documentation of past or current medical illnesses and hospitalizations 5
- Assessment of relevant past or current treatments, including surgeries 5
- Evaluation of past or current neurological or neurocognitive disorders 5
- Documentation of physical trauma, including head injuries 5
- Assessment of sexual and reproductive history 5
- For patients with current suicidal ideas: assessment of history of suicidal behaviors in biological relatives 6
- For patients with current aggressive ideas: assessment of history of violent behaviors in biological relatives 6
- Assessment of psychosocial stressors (financial, housing, legal, occupational, interpersonal problems) 7
- Review of the patient's trauma history 7
- Documentation of exposure to violence or aggressive behavior 7
- Assessment of legal or disciplinary consequences of past aggressive behaviors 7
- Evaluation of cultural factors related to the patient's social environment 7
- Assessment of patient's need for an interpreter 7
Implementation Considerations
- The evaluation may require several meetings with the patient, family, or others before completion 8
- The amount of time spent depends on the complexity of the problem, clinical setting, and patient's cooperation 8
- Information gathering should include face-to-face interview, review of medical records, physical examination, diagnostic testing, and history from collateral sources 9