A complete assessment addresses each of the following each visit, scaled to the patient's diagnosis and stability:
Mood — depressed mood, loss of interest or pleasure, and neurovegetative symptoms (sleep, appetite, energy, and concentration), screened with a validated tool (PHQ-2, then PHQ-9 if positive).
Anxiety — worry, restlessness, and physical symptoms, screened with a validated tool (GAD-7).
Risk of harm to self — screen for thoughts of self-harm; if present, assess risk and respond immediately per protocol (see Section 12).
Risk of harm to others — screen and respond per protocol when indicated.
Psychiatric symptoms — features of psychosis (hallucinations or delusions), mania, or severe agitation.
Substance use — screen for alcohol and other substance use.
The psychiatric history and current treatment — medication adherence, effect, and side effects — and the functional and safety impact.
Medical and medication contributors, including the possibility of delirium (assessed with Cognitive / Mental Status), and psychosocial stressors (assessed with Psychosocial / Caregiver).
