Description: This book and accompanying CD-ROM contain clinical forms for a psychiatrist to use, including an initial letter of contact, a self-assessment form, psychiatric history, and mental status examination, as well as consumer information on several disorders and many psychotropic drugs. The first edition was published in 1994.
Purpose: The purpose is to provide clinicians with forms which will be helpful in actual practice. This is an excellent idea because of the needs for a broad data collection on patients, the need for producing reports for third party payers, communication with other clinicians, and most importantly, to organize information in a usable, easily displayed manner to maximize data utilization by the clinician. The book goes further in meeting these objectives than any other I have seen.
Audience: It is written for "...medical students, psychiatric residents, and psychiatrists who are just starting their practices ... (and) More experienced psychiatrists...." I believe it is useful for psychiatrists at all levels because of its adaptability to any practitioners' work. The author is a world renowned research psychiatrist who has clearly wrestled with some of the problems of a practitioner.
Features: This book provides forms for explaining office procedures; requests for self-administered forms; initial psychiatric histories and forms; documentation of informed consent vis-a-vis medication; medication charts; and standardized psychiatric instruments such as the Abnormal Involuntary Movement Scale, Brief Psychiatric Rating Scale, Yale-Brown Obsessive Compulsive Scale, and Mini-Mental Status Exam. Finally, it includes information about major psychiatric disorders and a wide range of currently used medications intended for patients and their families. While each form and letter is clearly printed, it is also contained on a CD-ROM in two forms: a "*.pdf" file which can be printed using Adobe's Acrobat Reader (easily downloaded from the Internet); and a "*.doc" form which is written in Microsoft Word for Windows 6.0. The latter form may be modified using most word processors using Windows 95 or above. There are shortcomings in this compendium of forms. For example, the release of information would not be valid in many states, the history does not inquire about seizures or periods of unconsciousness, and the CAGE questionnaire is insensitive for heavy alcohol usage that might be detected before it becomes a diagnosable condition. The SCL-90 should have been included because of broader symptom evaluation. The material on medication for the patient contains some errors: nifedipine is not recommended for MAOI induced hypertensive crises; the ability of ACE inhibitors or low sodium diets generally favored by weight reduction programs to increase lithium levels is not mentioned. Finally, the material on diagnostic entities is written at the level higher than recommended for consumer materials.
Assessment: This publication has a great deal to offer the practitioner. In one place, it offers several important widely used instruments plus directions for their administration. The psychiatric history, information release forms, and material for patients and relatives can easily be modified to suit any practitioner's patient population and legal requirements within the state. I recommend them as starting points for psychiatric records which will be more complete, legible, and efficiently obtained. The second edition is certainly justified by the inclusion of the Y-BOCS, psychiatric history, and other forms, but most of all by their inclusion on a CD-ROM.