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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