Journal of Health and Biomedical Informatics

Introduction: Considering the importance of accurate documentation in psychiatric history and mental assessment and its effect on the current and future treatment among patients, this study aimed to determine data elements in the psychiatric history and mental assessment forms.

Method: This is a descriptive-comparative study. Using psychiatric history and assessment forms, the required data were gathered in this study. Finally, all psychiatric history and mental assessment forms gathered from the selected countries including the United States (n=9), Australia (n=1), France (n=1), Iran (n=2) were assessed. After preparing the comparative tables, a comprehensive list of data elements related to the psychiatric history and assessment was provided. Using bottom up approach the extracted data elements were categorized.

Results: In total, 58 data elements including demographic data, patient history, current symptoms of disease, evaluation of psychological states, suicide risk assessment, behavioral/emotional conditions, thinking process, drug abuse assessment, family safety/violence assessment, multi-axial diagnosis and treatment type/plan were extracted from psychiatric history and assessment forms.

Conclusion: The present study provides a general view of important data elements considered for documentation in psychiatric history and assessment forms.