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A. Inpatient Settings

The scope, pace, and depth of inpatient evaluation depend on the patient population served by the inpatient service, the goals of the hospitalization, and the role of the inpatient unit within the overall system of mental health services available to the patient (40, 41).

In addition to providing a highly structured and contained setting in which patient safety can be monitored and optimized, the inpatient setting permits intensive and continuous observation of signs and symptoms while the patient is being treated for psychiatric and general medical conditions through the collaborative efforts of the multidisciplinary treatment team (see also Section IV.A.5 ). Particularly for individuals with complex psychiatric presentations or multiple co-occurring disorders, the enhanced level of observation in the inpatient environment may facilitate assessment of co-occurring general medical conditions or evaluation for procedures such as electroconvulsive therapy, may aid in resolving diagnostic dilemmas, and may help in determining a patient's ability to function safely and independently in a less restrictive setting (41, 42).

Inpatient settings provide enhanced opportunity to corroborate clinical judgment and decision making, including discharge planning, through access to information from multiple sources. These include the multidisciplinary treatment team, family, friends, and individuals involved in the care of the patient outside the hospital, as well as prior hospitalization records.

From the outset, the inpatient evaluation should include assessment of the patient's access to appropriate treatment following hospitalization. The patient's living arrangements should also be assessed to determine whether they will continue to be suitable after discharge. If the posthospitalization disposition is not apparent, the evaluation should identify both patient factors and community resources that would be relevant to a viable disposition plan and should identify the problems that could impede a suitable disposition. Family involvement, when appropriate, can also be initiated, and goals for inpatient family work can be identified.

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B. Outpatient Settings

Outpatient settings differ widely, from office-based practices to community mental health centers to intensive outpatient or partial hospital programs, among others. Nevertheless, evaluation in the outpatient setting usually differs in intensity from inpatient evaluation because of less frequent interviews and less immediate availability of laboratory services and consultants from other medical specialties. Also, the psychiatrist in the outpatient setting has substantially less opportunity to directly observe the patient's behavior and to implement protective interventions when necessary. For this reason, during the period of evaluation it is important for the psychiatrist to reassess whether the patient requires hospitalization or more intensive outpatient care (e.g., greater visit frequency, intensive outpatient or partial hospital programs, programs of assertive community treatment). Unresolved questions about the patient's general medical status may also require more rapid assessment in a more structured setting. If the patient's presentation is atypical (e.g., with respect to symptoms, symptom severity, or age at onset), a more thorough medical workup may be required or coordinated with the patient's primary care physician. Patients who do not have a primary care physician may need assistance in obtaining appropriate referrals. A decision to change the setting for evaluation will depend on the patient's current mental status and behavior as well as the patient's history of psychiatric symptoms and treatment, the status of co-occurring general medical conditions or substance use, and the availability of diagnostic resources, therapeutic resources, and sociocultural supports.

Advantages of the outpatient setting include greater patient autonomy and the potential for a more longitudinal perspective on the patient's symptoms. However, the lack of continuous direct observation of behavior limits the obtainable data on how the patient's behavior appears to others. Consequently, extended evaluation of the patient in the context of psychoeducational or time-limited groups can complement and augment observations from one-to-one interviews. With the patient's permission, involvement of family or significant others as collateral sources in the evaluation process also deserves consideration. It is also useful to be aware that family and significant others may not be supportive of the patient or of psychiatric treatment. If the patient states that family systems issues, especially marital or partner issues, are a problem, an evaluation session with the partner can provide valuable information and clarify the systems issues. When substance use is suspected, obtaining data from other involved persons (e.g., family, close friends, staff), determining blood alcohol levels, or screening for substances of abuse may be especially important.

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C. General Medical Settings

Evaluations are also conducted in hospital emergency departments (see Section I.B) and general medical (i.e., nonpsychiatric) settings, such as inpatient units. The latter allow for some direct behavioral observation by staff and for some safeguards against self-injurious or other violent behavior by patients. However, the level of behavioral observation and potential intervention against risky behavior in these settings tends to be less than on psychiatric inpatient units. In addition, psychiatric interviews on general medical-surgical units are often compromised by interruptions and lack of privacy. These problems sometimes can be mitigated by using a space on the unit where the patient and the psychiatrist can meet privately.

Developing an ongoing relationship with staff on medical inpatient units will increase the likelihood of obtaining accurate behavioral data as well as of ensuring that staff implement recommendations. If there is prominent hostility or anxiety in interactions between the patient and hospital staff, the evaluating physician must consider interfacing with others in the hospital system to determine its contributors.

If the patient has an unclear sensorium or other cognitive impairments, it is critical to interview people in the patient's relational network to see if these symptoms were present before hospitalization or have developed since treatment was begun. In interviewing family members, it is very useful to discuss their beliefs about the patient's illness and prior treatment, the patient's record of adherence to medication treatment, and concerns about discharge planning. If family members do not perceive themselves as allies in treatment, the patient's treatment is likely to be compromised once he or she leaves the hospital (43).

Documentation of psychiatric evaluations in general medical charts should be sensitive to the standards of confidentiality of the nonpsychiatric medical sector and the possibility that charts may be read by persons who are not well informed about psychiatric issues. Information written in general medical charts should be confined to that necessary for the general medical team and should be conveyed with a level of detail and specificity that will be most helpful to the overall management of the patient. It is also important that documentation be of sufficient detail to establish a diagnosis and treatment plan.

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D. Other Settings

Evaluations conducted in other settings, such as residential treatment facilities, home care services, nursing homes, long-term care facilities, schools, and prisons, are affected by a number of factors: 1) the level of behavioral observations available and the quality of those observations, 2) the availability of privacy for conducting interviews, 3) the availability of general medical evaluations and diagnostic tests, 4) resources to conduct the evaluation safely, and 5) the degree of likelihood that information written in facility records will be understood and kept confidential.

In light of these factors, it is necessary to consider whether a particular setting permits an evaluation of adequate speed, safety, accuracy, and confidentiality to meet the needs of the patient. Factors of the setting that compromise the evaluation merit documentation.

References

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