Screen mood with the PHQ-2 and, if positive, the PHQ-9; screen anxiety with the GAD-7; document the scores and interpret them against the baseline.
Screen for thoughts of self-harm with a direct, compassionate, validated approach; if any are present, assess the level of risk and respond immediately per protocol — ensure safety first, escalate to the provider and to emergency or crisis services per severity, and mobilize crisis resources.
Assess for psychotic and manic symptoms and severe agitation, and screen substance use.
Evaluate psychiatric-medication adherence, effect, and side effects.
Distinguish a primary psychiatric presentation from a medical cause or delirium (an acute change is evaluated medically), and assess the support system and safety.
