The summary of the history and mental status is written up with each of the categories described including identification of the patient, chief complaint, history of present illness, past psychiatric history and medical history, family history, and so on. It includes a final summary of both positive and negative findings. Use specific examples of what questions are asked and how they are answered. Try to summarize the case not only from a descriptive approach, but also from an interpretive standpoint.

Clarity of thinking is reflected in clarity or writing and psychiatric terms should be used with precision. When summarizing the mental status, for example, the phrase “patient denies hallucinations and delusions” is not as precise as “patient denies hearing voices or thinking that he is being followed.” The latter indicates the specific questions asked and the specific response given. Similarly, in the conclusion of the report, one would write, “Hallucinations and delusions were not elicited.”

The examiner addresses critical questions in the report: Are future diagnostic studies needed, and if so, which ones? Is a consultant needed? Is a comprehensive neurological workup needed including an electroencephalogram (EEG) or computerized tomography (CT) scan? Are psychological tests indicated by a clinical psychologist? Are social work services needed?

Diagnostic classification is made according to the Diagnostic and Statistical Manual of Mental Disorders, Text Revision, fourth edition (DSM-IV-TR) (see Chapter 1).

The diagnosis is made using a multiaxial classification, which consists of five axes, each of which should be covered in the diagnosis. They are as follows: