Psychiatric history taking: the order, the questions and the write-up

Psychiatric history taking is the job you'll do most in your first psychiatry post. Usually it's an admission, often late in the day, sometimes with someone who doesn't want to be there.

Here's how I do it: the order I ask in, the questions I actually use, how I keep an admission to about an hour, and how I write it up. The mental state examination has its own guide, so I'll only touch on it here.

Before you go in

Ten minutes of preparation changes the whole interview. This is what I do first:

• Read what's already there. The referral, the last discharge summary, the most recent risk assessment and the drug chart. You'll ask better questions, and the patient won't have to repeat their life story for the fifth time.

• Check the legal status. Informal, or detained and under which section. It changes what you can offer and what they need to be told.

• Ask the nurse who admitted them. How they've been since arriving, whether they've eaten, slept or been drinking, and whether anything worries the team.

• Book an interpreter if you need one. NICE asks for an independent interpreter, meaning someone with no relationship with the patient. A relative can't keep things confidential, and may be part of the story.

• Plan for safety. Pick a room you can both leave easily, carry your alarm, and tell someone where you'll be. Never see patients by yourself !

Opening the interview

The first few minutes set the tone for the hour. Say who you are, why you're there and how long it will take:

"Hello, I'm Dr Joshi, one of the doctors on the ward. I'd like to hear what's been happening, in your own words, so we can work out how to help. It usually takes about an hour. Is now OK?"

Then confidentiality, with its limits said plainly:

"What you tell me stays within the team looking after you. The exception is if I'm worried about your safety or someone else's. Then I might need to share it, and I'd tell you first if I could."

Then ask one open question and stop talking:

"Can you tell me, from the beginning, what's led to you being here?"

The history of the presenting complaint

Let the story come first

For the first few minutes, mostly listen. Nod, say "go on", and resist the urge to start ticking boxes. The way someone tells the story is also your sample of their speech and thought for the mental state examination.

Once the story is out, build a timeline. The question I find most useful is:

"When did you last feel your usual self?"

Then work forward from that point:

• "What changed first?"

• "Was anything going on in your life around then?"

• "What's it been like over the last few days?"

• "Has anything helped, even a bit?"

• "How has it affected work, home, eating, sleep?"

• "What do you think is going on?"

• "What would you like to happen now?"

The last two matter more than they look. The patient's explanation and what they want from you shape whether they'll accept any plan you make.

Screen the rest

People tell you what troubles them most, which isn't always what matters for diagnosis. So I screen each main area briefly, whatever the presenting problem.

A yes opens up a fuller set of questions. A no takes ten seconds.

Ask about risk here

Ask about risk once the story is out and before the background. It belongs to the present, and if the patient tires, you'll already have it. Cover thoughts of suicide and self-harm, harm to others, and risk from others, including exploitation and neglect. Ask who depends on them, and whether they drive.

The step-by-step suicide questions are in the mental state examination guide. Here I'm also asking about the past: previous self-harm, what happened, and what has stopped them before.

The background history, in the order I take it

Signpost the change of gear so it doesn't feel like an interrogation:

"I'd like to ask about your background now. Some of it may seem unrelated, but it helps me understand the whole picture."

Past psychiatric history

Main thing to consider here is admission to psychiatric hospitals over time. It gives the most efficient impressions of how the psychopathology has evolved over time.

Medicines

Get the current medicines with doses, and ask how they're actually taking them: "Lots of people miss doses. How often does that happen for you?" Check the list against a second source, such as the GP record or the pharmacy. Ask about allergies, and about anything bought over the counter or herbal.

For past psychiatric medicines, record the dose, how long they took it, whether it helped, any side effects, and why it stopped. A drug named without a dose or a duration tells the next doctor nothing.

Physical health

Ask about long-term conditions, head injury, epilepsy and anything neurological. Ask what's been started or stopped recently. Some medicines cause psychiatric symptoms in their own right. The

Alcohol and drugs

Ask everyone, in a matter-of-fact tone. For alcohol, I use the three AUDIT-C questions: how often they drink, how much on a typical day, and how often they drink heavily in one session. The UK guidance says a score of 5 or more should prompt the full AUDIT

Then the dependence features, which ICD-11 groups as impaired control, increasing priority over other activities, and persisting despite harm. Physiological features may be present too: tolerance and withdrawal. On admission, the single most useful question is:

"When did you last have a drink, and what happens when you stop?"

For drugs, ask what, how much, how often, by what route, and whether they've ever injected or shared equipment. Ask how they pay for it. Ask about tobacco too. Stopping smoking on admission can raise the blood levels of clozapine and olanzapine, and nicotine replacement doesn't prevent that. Flag it to the team and the pharmacist, because the dose may need to come down.

Family history

Ask about mental illness in relatives, specifically about suicide, substance use, dementia and epilepsy. Ask about the family as it was when they were growing up and as it is now.

Personal history

Go through life in order: birth and milestones if they know them, childhood, school, qualifications, work and why each job ended. Then relationships and children. Ask gently about difficult childhood experiences, but don't press at a first meeting.

Social history

Ask where they live and with whom, whether it's secure, and how they manage money, benefits and debt. Find out who supports them and what a normal day looks like. Ask who depends on them: children, a partner they care for, an elderly parent. If someone is at home alone tonight because your patient is here, that's a job for now.

Forensic history

"Have you ever been in trouble with the police?" Then charges, convictions, prison, probation and any outstanding court dates.

Premorbid personality

"Before all this, how would your friends have described you?" Ask how they coped with stress and what they enjoyed. Someone in the middle of an episode describes the illness more than the person, so I check this with someone who knew them before.

Collateral history

Collateral history is the history from someone else: a relative, a carer, the GP, the care coordinator, or the notes from the police or ambulance crew. It matters most when insight is poor, memory is impaired, risk is a worry, or the story doesn't hang together.

If they don't want you to share anything, you can still listen. The GMC's confidentiality guidance says you shouldn't refuse to hear a relative's concerns on the grounds of confidentiality. The national consensus statement on information sharing and suicide prevention says the same.

What you can't do is pass on what the patient has asked you to keep private without good reason. Be careful not to confirm or deny what the relative thinks is wrong. Tell them you may need to let the patient know what they've said, if it shapes your assessment. Record each decision about sharing, and why you made it.

When I ring a relative, I usually start like this:

"I'm one of the doctors looking after your brother. I can't go into detail without his agreement, but I'd really value hearing what you've noticed."

Then ask:

• "When did you first notice a change?"

• "What's he like when he's well?"

• "Has he been taking his medication?"

• "Has he said or done anything that frightened you?"

• "What helped last time?"

Write down who told you what. Where accounts differ, record both and say they differ. The discrepancy is information in itself.

Writing up the psychiatric clerking

Use the same headings in the same order every time, so the next doctor can find the forensic history without reading everything. This is the structure I use:

PSYCHIATRIC CLERKING

Seen: [date, time, place] Present: [names and roles]

Legal status: [informal / section and date] Interpreter: [yes, language / no]

Sources: patient; [relative, GP, care coordinator]; [records read]

Reason for referral: [one line: who referred, and why now]

Presenting complaint: [in the patient's own words, quoted]

History of presenting complaint: [timeline from last well; triggers; last

few days; effect on function; their explanation; what they want]

Screening: [mood, mania, psychosis, anxiety and OCD, trauma, eating, memory]

Past psychiatric history: [episodes, diagnoses, admissions and legal status,

teams, early warning signs, previous self-harm or violence]

Medicines: [current, doses, adherence, checked against; past psychiatric

medicines with dose, duration, effect, side effects, why stopped]

Allergies:

Physical health: [conditions, head injury, epilepsy, recent drug changes]

Alcohol and drugs: [AUDIT-C, units a week, last drink, withdrawal history;

drugs, route, injecting; tobacco]

Family history: [illness by diagnosis, suicide; genogram if useful]

Personal history: [birth, development, childhood, school, work, relationships]

Social history: [housing, who lives there, money, support, dependants, driving]

Forensic history: [convictions, charges, outstanding dates; label allegations]

Premorbid personality: [patient's account; informant's account]

Collateral: [who, when, what they said; any discrepancies]

Mental state examination: [see the MSE template]

Risk: [to self, to others, from others; what raises it, what protects them]

Summary: [three or four lines]

Differential diagnosis: [working diagnosis first]

Plan: [observation level, physical checks and bloods, collateral to get,

medicines, who you discussed it with, review]

What I'd do on your next clerking

Ask your registrar or consultant to sit in on one and give you feedback. It's the quickest way I know to get better, and it can count as a workplace-based assessment.

Raj

References

1. National Institute for Health and Care Excellence. Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services (CG136). 2011. https://www.nice.org.uk/guidance/cg136

2. General Medical Council. Confidentiality: good practice in handling patient information. 2017, updated 2024. https://www.gmc-uk.org/professional-standards/the-professional-standards/confidentiality/using-and-disclosing-patient-information-for-direct-care

3. Department of Health and Social Care. UK clinical guidelines for alcohol treatment, chapter 3: identification and brief interventions. 2025. https://www.gov.uk/guidance/clinical-guidelines-for-alcohol-treatment/3-identification-and-brief-interventions