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SAMPLE MISTAKE

Mistake # 71 (taken from chapter 5 - Write-ups)

The past psychiatric history is not complete

The past psychiatric history should contain information about current clinicians (psychiatrists and/or therapists) and when they were last seen, hospitalization history, suicide attempt history, self-mutilation history, and psychiatric medication history. Not all patients will be able to provide all of this information, so look for collateral information such as the medical record, summaries from previous and/or current clinicians, and family or friends. The absence of any of these aspects of the history should also be noted.

Your past psychiatric history is complete if you have included:

• Names and contact information of current clinicians (psychiatrist, therapist, psychopharmacologist, social worker, group therapist, primary care physician)
• Dates of last and next appointments with current clinicians
• Prior hospitalizations (psychiatric/substance abuse), including age at first hospitalization, total number, reasons for hospitalization, location, voluntary/involuntary status, and date of last hospitalization
• Suicide attempt history, including number of attempts, methods, and lethality
• Self-mutilation history, including why the patient mutilates and the effect
• Psychiatric medications taken by the patient in the past, including indications for each medication, response, any adverse reactions, maximum dosages reached, and duration of treatment
• Psychotherapy trials, including type of therapy (insight-oriented, cognitive-behavioral, supportive, etc.), how it was helpful, frequency, and duration of therapy