Psychiatry Services

Psychiatric evaluation Psychiatric evaluation is the method by which the physician establishes a diagnosis of mental disorder and plan an intervention. In this assesment the physician investigates the symptoms of the person consulting and the factors that contribute to their emergence and maintenance, which can be briefly classified as psychological, social and somatic. This evaluation of the disorders uses a multiaxial system with base in several axes (I-II-III-IV-V) each one of which refers to a different information domain and that can help the physician to raise the treatment and to foresee the clinical evolution. Namely the axes are: I- Clinical disorders II- Personality disorders III- General physical states IV- Psychosocial problems V- Global Function Evaluation The central objective of a psychiatric evaluation should be: Establish a diagnosis Evaluate its severity and risk Evaluate the causes Establish a management plan Estimate a prognosis The integrated psychiatric evaluation has the form of a semi-structured interview with the patient and often with their family and closest friends and complemented by a general medical history, past medical and psychiatric history, use of controlled substances history, psychosocial and sociocultural history, occupational and military history, legal history, systems review, physical and mental examination, basic laboratory analysis and chest X-rays. Psychotherapy Psychotherapy is the treatment of mental illness and conduct disorders where the physician and other qualified healthcare professionals using a specified therapeutic communication, attempt to relieve emotional disturbances, revert or change deviant behavior patterns and promote the development and growth of the personality. Psychiatric documentation must include sufficient data justifying the medical necessity of the encounter, and enough information (history and examination) that leads to the diagnosis and treatment plan. The notes must show specific therapeutic interventions, how they are applied and treatment strategy. This documentation is essential to demonstrate the quality of service and good use. The documentation of an iteration plan is indispensable with short, medium and long term objectives. Evaluation and Management (E/M) The evaluation and management (E/M) services are documented and coded according to the nature of the problem that they present and the key components in the service. These components include clinical history, physical examination, and medical decision making, considering the complexity and/or severity of the situation. They must contain sufficient information to justify medical necessity and what is appropriate of the treatment. It also includes counseling and coordination of care. Notes of E/M must be kept separate from those of psychotherapy, but on the same record, for purposes of future audits. Counseling Counseling includes one or more of the following: · Discussion of studies results, impressions or recommendations of diagnostic studies · Prognosis · Risks and benefits of treatment options · Instructions related to the management of patient, and treatment options · Reduction of risk factors · Education of patient and his relatives Crisis Psychotherapy in a crisis situation is an urgent evaluation of the history that led to the situation, the mental state of the patient and the disposition of the case. The treatment includes psychotherapy, mobilization of resources necessary to resolve the crisis, restore the safety and implement the psychotherapeutic interventions necessary to minimize the potential psychological trauma. The problem usually represents a threat to the life and requires immediate attention. <a id="