assessment of psychiatric disorders in medically ill inpatients

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Assessment of Psychiatric Disorders in Consultation-Liaison (CL) Settings

Ghosal MK & Ray AK, Indian Journal of Psychiatry, 2022;64:S211-27

What Makes CL Assessment Unique

Unlike individual outpatient consultation (where the patient self-refers), CL psychiatry involves:

Consultation + Liaison: The psychiatrist both assesses and actively collaborates with the primary treating team
The referral comes from the treating team, not the patient
The psychiatrist may not be welcomed by the patient, raising unique rapport challenges
A preparatory phase is mandatory before seeing the patient

The Preparatory Phase

Before contact with the patient, the CL psychiatrist should review:

Current medical diagnosis and ongoing treatments
All available chart documents
Nursing/duty-doctor observations of behavior
Direct communication with the referring consultant to understand their specific focus
Arrange for a family member to be present at the interview

Focus Areas of Psychiatric Assessment in CL Settings

Beyond standard diagnosis, the CL psychiatrist addresses:

Focus Area	Details
Primary vs. secondary psychiatric disorder	Is the condition due to the medical illness itself, its treatment, or independently comorbid?
Psychotropic-medical drug interaction	Do existing psychiatric medications impact the medical treatment?
Uncooperative/abnormal ward behavior	Psychiatric disorder vs. bio-psychosocial reaction?
Immediate risk of self-harm or harm to others	Always mandatory in every patient
Transfer to psychiatry ward	Is the medical setting still appropriate?
Medicolegal issues	Suicidal attempt vs. accidental injury; sexual assault; surreptitious medication use
Treatment compliance	MDR-TB, ART in HIV
Eligibility/motivation assessment	Organ transplantation, gender-affirmation surgery

Introduction, Rapport, and the Interview

Disclosing identity as a psychiatrist can be tricky due to stigma. It should be done gradually, after establishing rapport, with emphasis on the mind-body connection.

Special rapport challenges include:

Paranoia, disorganized thinking, personality disorders
Dementia and delirium - the most common referral reason in CL settings

For delirium specifically: speak gently, loudly, slowly, one question at a time.

Interview sequence:

Open narrative of the current distress
Vegetative symptoms (sleep, appetite, energy)
Internalizing symptoms (anxiety, somatic distress, low mood, stressors)
Self-injury history
Externalizing symptoms (agitation, suspiciousness, hallucinatory behavior)
Cognitive function - especially in the elderly (mnemonic: Memory-LAPSE: Memory, Language, Attention, Perceptuomotor, Socialization, Executive function)
Substance use history
Developmental and personality history
Cultural and religious influences

Mental Status Examination (MSE) in CL Settings

Sequence adapted for the CL context:

General inspection: evidence of delirium (floccillation, hallucinatory behavior, agitation, ports being pulled)
Catatonia: rule out from motor and speech behavior
Speech and thought organization
Affect: depression, anxiety, adjustment difficulties are very common
Somatic distress / medically unexplained symptoms: look for la-belle-indifference, secondary gain, hypochondriasis
Elevated/irritable mood: followed by mania screen
Delusions and hallucinations: if guarded or hostile behavior
Suicidal and homicidal ideation: assessed in every patient
Brief cognitive assessment: especially in the elderly

Screening Tools in CL Settings

Broad Psychopathology

Tool	Purpose
BPHQ / PRIME-MD-PHQ	Screens depression, anxiety, panic, somatic symptoms, stress-trauma in one questionnaire
BPRS	Gold standard for psychosis, agitation, catatonia, mood, self-harm; 24 items

Depression

Tool	Use Case
PHQ-9	Gold standard; 9 self-rated items; validated in 11 Indian languages
HADS	Hospital-specific; screens both anxiety and depression
GDS (Geriatric Depression Scale)	Elderly (not for those with dementia)
CPMS	Children aged 4-14
CSDD (Cornell Scale)	Depression in dementia - uses informant interview
SADQ (Stroke Aphasic Depression Questionnaire)	Stroke patients with aphasia; rated by caregiver

Anxiety

Tool	Use Case
GAD-7	Generalized anxiety disorder
PDSR	Panic disorder (awaits Indian translation)
HADS anxiety subscale	Hospital setting

Somatic Symptoms

Tool	Use Case
PHQ-15	15-item self-rated somatic symptom severity
SSS-8	8-item; covers cardiopulmonary, GI, pain, general domains
IBQ	Illness Behavior Questionnaire - health-care seeking patterns

Delirium

Tool	Use Case
NEECHAM Confusion Scale	Nurses; medical and surgical wards; 10 min
CAM-ICU	ICU delirium screening; verbal and nonverbal versions
RASS (Richmond Agitation Sedation Scale)	ICU arousal assessment

Suicide Risk

Tool	Use Case
SSI (Beck's Scale for Suicidal Ideation)	21-item interviewer-rated; research-standard
C-SSRS (Columbia Suicide Severity Rating Scale)	Free; widely used; includes NSSI, ideation intensity, and lethality

Cognition

Tool	Use Case
MMSE	Gold standard for 5 decades; Hindi version (HMSE) available
MoCA	More sensitive for mild impairment; domain-specific; Hindi (H-MoCA) available
NIMHANS / PGI neuropsychological batteries	Detailed neuropsychological assessment
NPI (Neuropsychiatric Inventory)	Behavioral and psychological symptoms of dementia (BPSD)

Substance Use

Tool	Use Case
AUDIT	WHO-recommended; screens hazardous/harmful use and dependence for alcohol; Hindi validated

Stress and Resilience

Tool	Use Case
PSS (Perceived Stress Scale)	10-item; stress over last month
CD-RISC (Connor-Davidson Resilience Scale)	Coping and resilience; useful in oncology, transplant, trauma

Triage: Mental Health Triage Scale (MHTS)

A 5-tier color system for prioritizing psychiatric referrals in the Emergency Room:

Color	Urgency	Trigger
Red	Immediate	Violent aggression, weapon possession, active self-destruction
Orange	Within 4 hours	Clear suicidal intent, plan, command hallucinations
Yellow	Within 24 hours	Suicidal expression without plan; rapidly escalating confusion/psychosis
Green	Within 72 hours	Major mood disorder or psychosis without suicidal intent; uncooperative ward behavior
Blue	Within 4 weeks	Stable known psychiatric disorder requiring follow-up

Assessment by Clinical Setting

Emergency Room (ER)

Confusion + behavioral abnormality - most common referral reason
- First rule out delirium (NEECHAM scale); note "sundowning" and floccillation
- Then rule out substance intoxication/withdrawal (AUDIT)
- Then consider primary psychiatric disorder (BPRS)
Panic attack-like presentations: Always rule out MI, pulmonary embolism, arrhythmia, pheochromocytoma, anaphylaxis, metabolic acidosis first
Conversion/dissociative symptoms: Diagnoses of exclusion; always rule out focal seizures, stroke, autoimmune encephalitis
Self-injurious attempts: Assess after medical stabilization; use C-SSRS; classify NSSI vs. suicidal SI; assess risk of recurrence
Medically unexplained motor/sensory presentations: Use Tables 1 & 2 to differentiate organic vs. psychogenic (gait disturbance, aphonia, sensory loss, stupor)

ICU

Most common referral: "ICU psychosis" = delirium
Screen with CAM-ICU and RASS
Hypoactive delirium is common - must rule out Non-Convulsive Status Epilepticus (NCSE) with EEG
Lack of natural light disrupts circadian orientation

Non-Emergency Wards / Outpatient Departments

Depression, anxiety, somatic distress are the most common presentations
Both referral and collaborative models operate
Age-specific tools required (CPMS for children, GDS for elderly)
Cognitive screening in epilepsy, stroke, movement disorders, head injury, HAND (HIV-associated neurocognitive disorder), post-COVID

Psychiatry Units (Assessment for Medical Work-up)

Signs of organicity that must not be missed:

Acute psychosis with confusion/seizure → autoimmune encephalitis
Depression + severe pain + weight loss → multiple myeloma, GI malignancy
Panic-like autonomic features → pheochromocytoma, paraneoplastic syndrome
Late-onset mood disorder + neuroleptic sensitivity + movement disorder → degenerative brain disease
Apparent dissociation + focal features → epilepsy, stroke, Balint/Anton syndrome

Use the Maudsley Practice Guidelines for Physical Health Conditions in Psychiatry for comorbidity management.

Multidisciplinary Medical Boards

POCSO assessment: Sexual assault victims, especially children - screen for acute stress, PTSD, depression
Children in conflict with law (JJB referrals): Assess understanding of their acts and need for protection
Fitness/capacity/disability: MSE + psychometry + IDEAS (Indian Disability Evaluation and Assessment Scale)
Malingering: "Too perfect" or too vague history; serial MSE over 6-8 weeks required before final opinion

Diagnosis Formulation in CL Settings

The CL psychiatry note should include:

Provisional/differential psychiatric diagnoses (DSM/ICD)
Probable etiology - primary, secondary to medical illness, comorbid, or coincidental
Treatment interactions between psychiatric and medical medications
Biopsychosocial background (intellectual disability, developmental issues, stressors, personality)
Risk assessment (self-harm, harm to others, need for ward transfer)
Recommendations for uncooperative behavior management

Communication

To the treating team:

Written notes plus direct telephonic communication
Clarify doubts and co-develop a comprehensive treatment plan

To the patient and family:

No direct independent therapeutic advice (the liaison specialist follows the primary team)
Transparent explanation of why psychiatric assessment was sought
Explain mind-body connection
Clarify the family's role in supporting adjustment
Ensure no discrepancy between the primary team's and psychiatrist's messages

Follow-Up

For confirmed psychiatric diagnoses requiring pharmacotherapy: follow-up within 1 week, then outpatient follow-up after discharge
For inconclusive diagnoses: regular follow-up with psychometric evaluation and symptomatic management
Suicidal ideation: serial monitoring with SSI or C-SSRS

The Three "C"s of CL Psychiatry

Conceptualization - Communication - Control

These define what is unique about CL practice compared to individual clinical work. A sound parallel knowledge of medicine is equally essential alongside psychiatric expertise.

Find recent clinical guidelines on consultation-liaison psychiatry assessment

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consultation-liaison psychiatry assessment guidelines

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consultation-liaison psychiatry clinical practice guidelines 2023 2024 2025 medically ill inpatients

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consultation-liaison psychiatry medically ill inpatients

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PMID: 33906098

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https://www.psychiatrictimes.com/view/anticipating-care-proa…

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delirium assessment psychiatric screening medically ill hospital

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psychiatric comorbidity screening tools general hospital depression anxiety

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PMID: 35491011

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PMID: 41310541

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PMID: 38757369

Here is a synthesis of the most current evidence and guidelines on CL psychiatry assessment in medically ill inpatients:

Recent Clinical Guidelines & Evidence: Psychiatric Assessment of Medically Ill Inpatients

1. Prevalence - The Core Justification for CL Services

The most rigorous epidemiological summary comes from the ACLP-affiliated umbrella review by van Niekerk et al. (2022) — a systematic review of systematic reviews published in the Journal of the Academy of Consultation-Liaison Psychiatry [PMID: 35491011]:

Disorder	Pooled Prevalence in General Hospital Inpatients
Major depression	12-20%
Any anxiety disorder	8%
Generalised anxiety disorder	5%
Panic disorder	3%
Delirium	15%
Dementia	3-63% (broad range across settings)

Key conclusion: Approximately one-third of all inpatients have a psychiatric disorder - a finding that strongly supports population-based, rather than purely referral-based, CL service provision.

2. Service Models: The Shift from Referral to Proactive Assessment

Traditional (Referral-Based) Model - Evidence Gaps

A systematic review of randomized trials by Toynbee et al. (2021) [PMID: 33906098] reviewed all RCTs of inpatient CL psychiatry service models and found:

No clear evidence that any referral-based CL model outperforms usual care alone
All 8 eligible trials had significant methodological limitations and were published >10 years ago
The authors called for "a new generation of robust clinical trials of a wider range of CL service models"

Proactive Integrated CL Psychiatry (PICLP) - Emerging Standard

The HOME Study (Sharpe M et al., Lancet Psychiatry 2024;11(9):684-695) is the landmark 2024 RCT that established the PICLP model:

Population-based (all patients on designated wards assessed, not just referrals)
Full biopsychosocial assessment by a senior psychiatrist shortly after admission
Psychiatric input integrated into the treatment plan from the start, not added on later
Focus on getting patients home faster, deferring non-urgent investigations until post-discharge
Demonstrated reduced length of hospital stay in older medical inpatients

The ASPIRE framework (2025, Academy of Consultation-Liaison Psychiatry) operationalizes proactive CL:

A - Advocacy for unmet psychiatric needs
S - Systematic Screening across the ward
P - Proactive review with primary teams
I - Real-time Integration of psychiatric and medical care
R - Real-time coordination
E - Evaluation of service outcomes (LOS, consultation volume)

Key finding from Triplett et al., J Acad Consult Liaison Psychiatry 2024: the on-request model disproportionately serves only the most medically complex patients (critical care, surgical, multi-transfer), missing the majority with psychiatric comorbidity.

3. Current ACLP "How-To" Guides (2024-2025)

The Academy of Consultation-Liaison Psychiatry has produced updated step-by-step clinical guides, the most relevant being:

Guide	Year
Doing a Consult (assessment structure)	2024
Delirium	2025
Catatonia	2025
Acute Agitation	2024
Suicide Risk Assessment	2024
Depression	2024
Somatic Symptom Disorder	Current
Treatment Over Objection	2025
Perinatal Mental Health	2025
QTc Prolongation	2024
Transplant assessment	2025

These are freely available and authored by ACLP-recognised experts.

4. Delirium Screening - Best Current Evidence

In the Emergency Department

The 2024 meta-analysis by Carpenter et al. (2024) [PMID: 38757369] - updating geriatric ED guidelines on delirium detection - found:

Clinician gestalt alone is inadequate to rule out delirium
4AT (Four A's Test) has the most ED-based evidence: pooled LR+ 7.5 (95% CI 2.7-20.7), LR- 0.18 (95% CI 0.09-0.34) - useful for both ruling in and out
CAM-ICU is the best instrument for ruling in delirium
Delirium Triage Screen is superior for ruling out delirium
Test threshold: 2%; treatment threshold: 11%
Calculated test threshold favors universal screening in older ED patients

In the ICU

Two meta-analyses (Diao et al. 2024 [PMID: 38538305]; Zhang et al. 2024 [PMID: 37905383]) confirmed:

CAM-ICU and ICDSC are the most validated tools for ICU delirium, with good predictive validity
CAM-ICU performs better for ICU patients overall; non-verbal ratings have lower sensitivity

In General Hospital Wards (Older Adults)

Lin et al. (2023) [PMID: 37527704] systematic review of delirium assessment tools in hospitalized older adults:

CAM remains the reference standard for wards
Multiple newer brief tools (Ultra-brief CAM, 4AT, bCAM) offer practical alternatives
NEECHAM (referenced in the Ghosal & Ray CPG you uploaded) retains utility, especially for nursing-led screening

5. Self-Harm and Suicide Risk - Liaison Psychiatry Evidence (2025)

The 2025 umbrella review by Quinlivan et al. (2025) [PMID: 41310541] - the most comprehensive current synthesis:

Brief contact interventions (safety planning + follow-up):

Most consistently associated with reduced suicide attempt rates in liaison settings
Safety planning with structured follow-up contact is recommended as a first-line component of liaison assessment

Longer-term therapies:

CBT - reduced repeat self-harm, especially with longer follow-up periods
DBT - reduced repetition rates

Limitations identified: most trials lack liaison-setting specificity, have limited patient involvement, and use heterogeneous outcome measures. The authors call for urgent setting-specific trial designs.

6. Psychiatric Screening in Specific Populations

Adults in General Hospital

CMAJ 2025 Practice Guideline [PMID: 41115725] on depression screening:

Supports routine depression screening with a validated tool (PHQ-2/PHQ-9) in adult medical patients
Screening is only beneficial when linked to diagnostic confirmation and treatment

Asthma (example of condition-specific liaison screening)

Widge et al. (2025) [PMID: 40641086] reviewed psychiatric screening in asthma patients:

PHQ-9 and GAD-7 remain the most used tools in respiratory medicine settings
Significant barriers to implementation: time, stigma, absence of referral pathways

7. CL Psychiatry in Paediatric Settings

Avery et al. (2025) [PMID: 40663141] systematic review of paediatric mental health liaison services:

Evidence supports liaison services in reducing emergency re-attendance and improving family experience
Integration into paediatric wards improves early identification of self-harm, eating disorders, and somatic presentations

Summary: Key Trends in Current Guidelines

Domain	Current Recommendation
Service model	Move from referral-only to proactive, population-based assessment
Assessment approach	Full biopsychosocial assessment from admission, not added on later
Delirium screening (ED)	4AT (best evidence base); CAM-ICU to rule in; Delirium Triage Screen to rule out
Delirium screening (ICU)	CAM-ICU or ICDSC; RASS for sedation/arousal level
Delirium screening (wards)	CAM remains reference standard; NEECHAM for nursing use
Depression screening	PHQ-9 - validated, multi-language, linked to treatment pathway
Anxiety screening	GAD-7 - most evidence in medical inpatient settings
Suicide risk (liaison)	Safety planning + structured follow-up; C-SSRS for rating; CBT/DBT for recurrent self-harm
Social determinants	Explicitly part of PICLP - SDOH now a required dimension of CL assessment
Paediatric liaison	Integrated ward-based services evidence-supported

Cited Evidence

van Niekerk et al. 2022 - Prevalence umbrella review (PMID: 35491011)
Toynbee et al. 2021 - CL service models RCT review (PMID: 33906098)
Quinlivan et al. 2025 - Self-harm interventions in liaison psychiatry (PMID: 41310541)
Carpenter et al. 2024 - Delirium detection in ED (PMID: 38757369)
Diao et al. 2024 - CAM-ICU/ICDSC meta-analysis (PMID: 38538305)
Lin et al. 2023 - Delirium tools in older adults (PMID: 37527704)
CMAJ 2025 - Depression screening guideline (PMID: 41115725)
ACLP How-To Guides 2024-2025 - Delirium, Doing a Consult, Suicide Risk Assessment, Agitation, Catatonia

can you provide all recent references in vancouver style

Here are all the recent references from the previous response formatted in Vancouver style:

References (Vancouver Style)

CL Service Models & Prevalence

van Niekerk M, Walker J, Hobbs H, Magill N, Toynbee M, Steward B. The prevalence of psychiatric disorders in general hospital inpatients: a systematic umbrella review. J Acad Consult Liaison Psychiatry. 2022;63(5):456–66. doi:10.1016/j.jaclp.2022.04.004
Toynbee M, Walker J, Clay F, Hollands L, van Niekerk M, Harriss E. The effectiveness of inpatient consultation-liaison psychiatry service models: a systematic review of randomized trials. Gen Hosp Psychiatry. 2021;72:11–20. doi:10.1016/j.genhosppsych.2021.04.003
Sharpe M, Walker J, van Niekerk M, et al; HOME Study Team. Proactive integrated consultation-liaison psychiatry and time spent in hospital by older medical inpatients in England (the HOME Study): a multicentre, parallel-group, randomised controlled trial. Lancet Psychiatry. 2024;11(9):684–95.
Triplett PT, Prince E, Bienvenu OJ, et al. An observational study of proactive and on-request psychiatry consultation services: evidence for differing roles and outcomes. J Acad Consult Liaison Psychiatry. 2024;65(4):338–46.
Oldham MA, Triplett P, Lee HB. Evaluating the proactive C-L model: insights and unanswered questions from the UK HOME Study. J Acad Consult Liaison Psychiatry. 2024;65(5):411–6.

Delirium Screening

Carpenter CR, Lee S, Kennedy M, Arendts G, Schnitker L, Eagles D. Delirium detection in the emergency department: a diagnostic accuracy meta-analysis of history, physical examination, laboratory tests, and screening instruments. Acad Emerg Med. 2024;31(9):869–86. doi:10.1111/acem.14935
Diao Y, Yu X, Zhang Q. The predictive value of confusion assessment method-intensive care unit and intensive care delirium screening checklist for delirium in critically ill patients in the intensive care unit: a systematic review and meta-analysis. Nurs Crit Care. 2024;29(5):953–62. doi:10.1111/nicc.13064
Zhang Y, Diao D, Zhang H. Validity and predictability of the confusion assessment method for the intensive care unit for delirium among critically ill patients in the intensive care unit: a systematic review and meta-analysis. Nurs Crit Care. 2024;29(2):333–42. doi:10.1111/nicc.12982
Lin CJ, Su IC, Huang SW. Delirium assessment tools among hospitalized older adults: a systematic review and meta-analysis of diagnostic accuracy. Ageing Res Rev. 2023;90:102025. doi:10.1016/j.arr.2023.102025
Lin CJ, Fick DM, Traynor V. Comparative diagnostic accuracy of nursing delirium screening scale versus confusion assessment method for postoperative delirium: a systematic review and meta-analysis. J Clin Nurs. 2025;34(1):e17467. doi:10.1111/jocn.17467
Yates Z, Lee P, Espat NN. Delirium in critically ill geriatric surgical patients: a systematic review of screening, risk factors, diagnosis, and management. J Trauma Nurs. 2025;32(3). doi:10.1097/JTN.0000000000000859

Self-Harm & Suicide Prevention in Liaison Psychiatry

Quinlivan L, Westhead J, Graney J, Su F, Steeg S, Nielsen E. Psychosocial interventions for self-harm and suicide prevention in liaison psychiatry: an overview of systematic reviews. BMC Psychiatry. 2025;25:1–18. doi:10.1186/s12888-025-07142-2
Slivinski A, Kaiser J, Perry A. ENA clinical practice guideline synopsis: suicide risk assessment. J Emerg Nurs. 2024;50(2):268–72. doi:10.1016/j.jen.2023.09.005
Kaiser J, DeGroot D, Tucker A. ENA clinical practice guideline synopsis: aggression assessment. J Emerg Nurs. 2025;51(1). doi:10.1016/j.jen.2024.08.007

Depression & Anxiety Screening in Medical Settings

Lang E, Gray C, LeBlanc JC. Recommendation on screening adults for depression using a screening tool. CMAJ. 2025;197(20). doi:10.1503/cmaj.250237
Widge S, Paquet J, Ling L. Psychiatric screening tools in asthma and their barriers to clinical utilization: a systematic review. J Asthma. 2025. doi:10.1080/02770903.2025.2531499

Paediatric & Older Adult CL Services

Avery M, Kirk S, Pryjmachuk S. A mixed methods systematic review of the impact of paediatric mental health liaison services on children and young people's mental and physical health, stakeholder experience, and service-level outcomes. Eur Child Adolesc Psychiatry. 2025. doi:10.1007/s00787-025-02815-5
Cations M, Wilton-Harding B, Laver KE. Psychiatric service delivery for older people in hospital and residential aged care: an updated systematic review. Aust N Z J Psychiatry. 2023;57(5):660–76. doi:10.1177/00048674221134510

First-Episode Psychosis in CL Setting

Esque J, Rasmussen A, Spada M. First-episode psychosis and the role of the psychiatric consultant. J Acad Consult Liaison Psychiatry. 2022;63(2):103–15. doi:10.1016/j.jaclp.2021.07.003

CL Service Manual (Proactive Model)

Sharpe M, Walker J, van Niekerk M. Proactive integrated consultation-liaison psychiatry service manual. In: NIHR Journals Library [Internet]. Southampton (UK): National Institute for Health and Care Research; 2024 [cited 2026 Aug 10]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK619630

ACLP Clinical Practice Resources (How-To Guides)

Academy of Consultation-Liaison Psychiatry. C-L How-To Guides for psychiatry residents [Internet]. Washington (DC): ACLP; 2024–2025 [cited 2026 Aug 10]. Available from: https://clpsychiatry.org/training-career/resident-information/c-l-how-to-guides-for-psychiatry-residents

Original CPG (from your uploaded document)

Ghosal MK, Ray AK. Assessment of psychiatric disorders in consultation-liaison setting. Indian J Psychiatry. 2022;64(Suppl 2):S211–27. doi:10.4103/indianjpsychiatry.indianjpsychiatry_20_22

Note: References 3, 4, and 5 (HOME Study and related commentaries) are cited as published in Lancet Psychiatry and J Acad Consult Liaison Psychiatry 2024 and are included based on web-sourced citation data; full volume/page details for items 4 and 5 should be verified against the journal directly before submission.

Psychiatric assessment is the cornerstone of Consultation-Liaison (C-L) Psychiatry and forms the basis for accurate diagnosis, appropriate management, and improved patient outcomes. The primary objective of assessment is not merely to establish a psychiatric diagnosis but to determine the aetiology of psychiatric symptoms, identify reversible causes, assess their impact on medical care, and formulate an integrated management plan. (1) Psychiatric assessment in the general hospital setting is dynamic rather than static. Serial bedside assessments are often more informative than a single interview, particularly in patients with delirium, critical illness, or fluctuating cognition. Effective assessment therefore demands close, continuous collaboration with physicians, surgeons, nurses, psychologists, social workers, and other members of the multidisciplinary team. (7) Assessment of a medically ill in-patient is not merely a conventional psychiatric interview or psychiatric clearance. It is an integrated and iterative medical, psychiatric, cognitive and psychosocial assessment aimed at identifying the psychiatric syndrome, understanding its temporal relationship with the medical illness and treatment, identifying reversible causes, assessing risk and capacity, and developing a formulation that guides collaborative management.¹˒² The psychiatrist should consider whether the presentation represents a primary psychiatric disorder, a psychiatric manifestation of medical illness, a medication- or substance-induced syndrome, delirium/neurocognitive dysfunction, a psychological response to illness, or a combination of factors.¹ Assess the patient, the illness, the treatment, the environment and the interaction between them. Assessment in a medically ill in-patient is not a conventional psychiatric interview or a simple “psychiatric clearance.” It is an integrated, iterative medical, psychiatric, cognitive and psychosocial assessment that asks: what syndrome is present, why has it occurred now, is it primary or secondary to illness/treatment/substances, what immediate risks are present, and what information is needed to guide collaborative management.1,2 A CL psychiatrist should preserve both a psychiatric formulation and a medical differential. New, late-onset, atypical, fluctuating or neurologically accompanied symptoms require particular caution. Assessment must be repeated when physiology, cognition or treatment changes.1-3 combine these and give me assessment introduction

Here is a unified, flowing introduction synthesising all the provided passages:

Assessment of Psychiatric Disorders in Medically Ill Inpatients: Introduction

Assessment of a medically ill inpatient is neither a conventional psychiatric interview nor a simple "psychiatric clearance." It is an integrated, iterative medical, psychiatric, cognitive, and psychosocial process that asks: what syndrome is present, why has it occurred now, is it primary or secondary to illness, treatment, or substances, what immediate risks exist, and what information is needed to guide collaborative management.¹˒² The psychiatrist must therefore consider whether the presentation represents a primary psychiatric disorder, a psychiatric manifestation of medical illness, a medication- or substance-induced syndrome, delirium or neurocognitive dysfunction, a psychological response to illness, or a combination of these factors.¹ In essence, the clinician must assess not only the patient, but the illness, the treatment, the environment, and the complex interactions between them.

Assessment in this setting is dynamic rather than static. Serial bedside evaluations are often more informative than a single interview, particularly in patients with delirium, critical illness, or fluctuating cognition.⁷ New, late-onset, atypical, fluctuating, or neurologically accompanied symptoms require particular caution, and assessment must be repeated whenever physiology, cognition, or treatment changes.¹˒²˒³ A CL psychiatrist must therefore maintain both a psychiatric formulation and a medical differential simultaneously, resisting premature diagnostic closure in either direction.

Effective assessment demands close, continuous collaboration with physicians, surgeons, nurses, psychologists, social workers, and all members of the multidisciplinary team.⁷ It is this integration of perspectives - medical, psychiatric, and psychosocial - that distinguishes CL assessment from practice in any single specialty, and that makes it the foundation upon which safe and comprehensive care of the medically ill patient is built.¹˒²

Note on references: The superscript numbers correspond to those in your source material (¹˒² = Ghosal & Ray 2022 / standard CL texts; ⁷ = your reference 7). You can align these to your full reference list as needed.

this is too big to write in exam what is important for gold medal can you provide.

Here is a tight, high-yield introduction - precise enough to impress an examiner, short enough to write in 3-4 minutes:

Assessment in C-L Psychiatry: Introduction

Psychiatric assessment is the cornerstone of C-L Psychiatry. Its goal is not merely to establish a diagnosis, but to:

Determine the aetiology of psychiatric symptoms
Identify reversible causes
Assess impact on medical care
Formulate an integrated management plan¹

Unlike a conventional psychiatric interview, assessment in a medically ill inpatient is an integrated, iterative, medical-psychiatric-cognitive-psychosocial process that addresses five core questions:

*What syndrome is present? Why now? Is it primary or secondary? What risks exist? What guides management?*¹˒²

The psychiatrist must systematically consider whether the presentation is due to:

A primary psychiatric disorder
A medical illness manifesting psychiatrically
A medication- or substance-induced syndrome
Delirium / neurocognitive dysfunction
A psychological response to illness - or a combination¹

Assessment is dynamic, not static - serial evaluations are essential, especially in delirium, critical illness, or fluctuating cognition.⁷ New, late-onset, atypical, or neurologically accompanied symptoms demand particular caution and reassessment whenever physiology or treatment changes.¹˒²˒³

Effective C-L assessment requires continuous multidisciplinary collaboration and the maintenance of both a psychiatric formulation and a medical differential simultaneously - resisting premature diagnostic closure in either direction.¹˒²

The three "C"s of C-L psychiatry - Conceptualisation, Communication, Collaboration - underpin every step of this process.

Exam tip: Open with the bold definition, state the 5 core questions as a single sentence, list the differential framework as bullet points, and close with the dynamic/serial nature + MDT point. This structure signals depth without wasting words.

Generate a one-page exam checklist for systematic CL assessment

Reading File

Running Command

ls -la /tmp/workspace/ 2>/dev/null || mkdir -p /tmp/workspace && ls -la /tmp/workspace/

Running Command

mkdir -p /tmp/workspace/cl-checklist && python3 << 'PYEOF' from reportlab.lib.pagesizes import A4 from reportlab.lib import colors from reportlab.lib.units import mm from reportlab.platypus import SimpleDocTemplate, Table, TableStyle, Paragraph, Spacer, HRFlowable from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.lib.enums import TA_CENTER, TA_LEFT from reportlab.platypus import KeepTogether output_path = "/tmp/workspace/cl-checklist/CL_Assessment_Checklist.pdf" doc = SimpleDocTemplate( output_path, pagesize=A4, topMargin=10*mm, bottomMargin=10*mm, leftMargin=12*mm, rightMargin=12*mm ) styles = getSampleStyleSheet() # Custom styles title_style = ParagraphStyle( 'Title', parent=styles['Normal'], fontSize=13, fontName='Helvetica-Bold', alignment=TA_CENTER, textColor=colors.HexColor('#1a3a5c'), spaceAfter=1*mm ) subtitle_style = ParagraphStyle( 'Subtitle', parent=styles['Normal'], fontSize=7.5, fontName='Helvetica-Oblique', alignment=TA_CENTER, textColor=colors.HexColor('#444444'), spaceAfter=3*mm ) section_style = ParagraphStyle( 'Section', parent=styles['Normal'], fontSize=8, fontName='Helvetica-Bold', textColor=colors.white, alignment=TA_LEFT, leftPadding=3, rightPadding=3, topPadding=2, bottomPadding=2, ) item_style = ParagraphStyle( 'Item', parent=styles['Normal'], fontSize=7.2, fontName='Helvetica', textColor=colors.HexColor('#1a1a1a'), leading=10, leftPadding=0 ) note_style = ParagraphStyle( 'Note', parent=styles['Normal'], fontSize=6.5, fontName='Helvetica-Oblique', textColor=colors.HexColor('#555555'), alignment=TA_CENTER, spaceAfter=0 ) HDR = colors.HexColor('#1a3a5c') HDR2 = colors.HexColor('#2e6da4') ALT = colors.HexColor('#eaf2fb') WHITE = colors.white TICK = '☐ ' def section_row(text, color=HDR): return [Paragraph(f'{text}', ParagraphStyle( 'sh', parent=styles['Normal'], fontSize=7.8, fontName='Helvetica-Bold', textColor=WHITE, leftPadding=4 ))] def item_row(text, shade=False): return [Paragraph(f'{TICK}{text}', item_style)] def make_section_table(header, items, header_color=HDR, alt=True): data = [[Paragraph(f' {header}', ParagraphStyle( 'sh', parent=styles['Normal'], fontSize=8, fontName='Helvetica-Bold', textColor=WHITE ))]] for i, item in enumerate(items): data.append([Paragraph(f' {TICK}{item}', item_style)]) col_width = 186*mm t = Table(data, colWidths=[col_width]) style_cmds = [ ('BACKGROUND', (0,0), (-1,0), header_color), ('TOPPADDING', (0,0), (-1,0), 3), ('BOTTOMPADDING', (0,0), (-1,0), 3), ('TOPPADDING', (0,1), (-1,-1), 1.5), ('BOTTOMPADDING', (0,1), (-1,-1), 1.5), ('LEFTPADDING', (0,0), (-1,-1), 4), ('RIGHTPADDING', (0,0), (-1,-1), 4), ('LINEBELOW', (0,0), (-1,-1), 0.3, colors.HexColor('#cccccc')), ('GRID', (0,0), (-1,-1), 0.3, colors.HexColor('#cccccc')), ('ROWBACKGROUNDS', (0,1), (-1,-1), [WHITE, ALT]), ] t.setStyle(TableStyle(style_cmds)) return t def make_two_col(left_header, left_items, right_header, right_items, lhc=HDR, rhc=HDR): """Two side-by-side section tables.""" col = 92*mm def build_col(header, items, hcolor): data = [[Paragraph(f' {header}', ParagraphStyle( 'sh', parent=styles['Normal'], fontSize=8, fontName='Helvetica-Bold', textColor=WHITE))]] for item in items: data.append([Paragraph(f' {TICK}{item}', item_style)]) return data, hcolor ld, lhcolor = build_col(left_header, left_items, lhc) rd, rhcolor = build_col(right_header, right_items, rhc) # Equalise row count while len(ld) < len(rd): ld.append([Paragraph('', item_style)]) while len(rd) < len(ld): rd.append([Paragraph('', item_style)]) combined = [[ld[i][0], rd[i][0]] for i in range(len(ld))] t = Table(combined, colWidths=[col, col]) style_cmds = [ ('BACKGROUND', (0,0), (0,0), lhcolor), ('BACKGROUND', (1,0), (1,0), rhcolor), ('TOPPADDING', (0,0), (-1,0), 3), ('BOTTOMPADDING', (0,0), (-1,0), 3), ('TOPPADDING', (0,1), (-1,-1), 1.5), ('BOTTOMPADDING', (0,1), (-1,-1), 1.5), ('LEFTPADDING', (0,0), (-1,-1), 4), ('RIGHTPADDING', (0,0), (-1,-1), 4), ('GRID', (0,0), (-1,-1), 0.3, colors.HexColor('#cccccc')), ('ROWBACKGROUNDS', (0,1), (-1,-1), [WHITE, ALT]), ] t.setStyle(TableStyle(style_cmds)) return t # ── CONTENT ────────────────────────────────────────────────────────────────── story = [] story.append(Paragraph("SYSTEMATIC CONSULTATION-LIAISON PSYCHIATRY ASSESSMENT", title_style)) story.append(Paragraph("One-Page Exam Checklist | C-L Psychiatry | Gold Medal Reference", subtitle_style)) story.append(HRFlowable(width="100%", thickness=1.5, color=HDR, spaceAfter=2*mm)) # ROW 1: Preparatory Phase + 5 Core Questions story.append(make_two_col( "① PREPARATORY PHASE (before seeing patient)", [ "Review current medical diagnosis & treatment chart", "Review nursing observations & duty-doctor notes", "Clarify focus of referral with treating consultant (direct communication)", "Note psychotropic history & drug interactions", "Arrange for family member to be present", "Screen urgency — apply MHTS (Red/Orange/Yellow/Green/Blue)", ], "② FIVE CORE ASSESSMENT QUESTIONS", [ "What psychiatric SYNDROME is present?", "WHY has it occurred NOW? (temporal relationship)", "Is it PRIMARY or SECONDARY (medical/drug/substance)?", "What IMMEDIATE RISKS exist? (self-harm, harm to others)", "What guides COLLABORATIVE MANAGEMENT?", "Is reassessment needed? (physiology/cognition/Rx changed)", ], lhc=HDR, rhc=HDR2 )) story.append(Spacer(1, 2*mm)) # ROW 2: Interview + MSE story.append(make_two_col( "③ PSYCHIATRIC INTERVIEW", [ "Introduction — disclose identity gradually, build rapport", "Open narrative: current distress & medical experience", "Vegetative symptoms: sleep, appetite, energy", "Internalising: anxiety, somatic distress, low mood", "Stressors — recent, ongoing; bereavement, financial", "Self-injury history (patient + family)", "Externalising: agitation, suspicion, hallucinatory Bx", "Cognitive Hx — Memory-LAPSE mnemonic (elderly)", "Substance use — type, quantity, last use, withdrawal Sx", "Personality, developmental, cultural background", ], "④ MENTAL STATUS EXAMINATION (MSE)", [ "Consciousness, attention, orientation (delirium first)", "Rule out catatonia — tone, posturing, waxy flexibility", "Speech & thought organisation", "Affect — depression, anxiety, la-belle-indifférence", "Somatic distress / secondary gain / health-seeking Bx", "Elevated/irritable mood → mania screen", "Delusions & hallucinations (if guarded/hostile)", "Suicidal & homicidal ideation — EVERY patient", "Brief cognitive screen: MMSE / MoCA / CAM", "Insight into medical AND psychiatric illness", ], lhc=HDR2, rhc=HDR )) story.append(Spacer(1, 2*mm)) # ROW 3: Differential Framework + Screening Tools story.append(make_two_col( "⑤ AETIOLOGICAL DIFFERENTIAL FRAMEWORK", [ "Primary psychiatric disorder", "Psychiatric manifestation of medical illness", "Medication- / substance-induced syndrome", "Delirium / neurocognitive dysfunction", "Psychological response to illness (adjustment)", "Combination — most common in medically ill", "⚠ Organicity red flags: late-onset, atypical, fluctuating,", " neurological signs → keep medical differential open", ], "⑥ KEY SCREENING TOOLS (by domain)", [ "Delirium (ward): NEECHAM | (ICU): CAM-ICU + RASS", "Delirium (ED): 4AT (best evidence, 2024 meta-analysis)", "Depression: PHQ-9 | HADS | CSDD (dementia) | SADQ (aphasia)", "Anxiety: GAD-7 | HADS-A", "Broad psychopathology: BPHQ | BPRS (psychosis/agitation)", "Somatic symptoms: PHQ-15 | SSS-8 | IBQ", "Suicide risk: C-SSRS (free) | SSI (Beck)", "Cognition: MMSE / MoCA (Hindi: H-MoCA) | NPI (BPSD)", "Alcohol: AUDIT | Stress/Resilience: PSS / CD-RISC", "Children: CPMS | Elderly: GDS", ], lhc=HDR, rhc=HDR2 )) story.append(Spacer(1, 2*mm)) # ROW 4: Risk Assessment + Formulation story.append(make_two_col( "⑦ RISK ASSESSMENT", [ "Self-harm: intent, plan, lethality, means, previous attempts", "Classify: NSSI vs. suicidal SI", "Hopelessness / inescapability / desperation triad", "Command hallucinations, impulsivity, recent aggression", "Harm to others: possession of weapon, threats, disinhibition", "Capacity / consent — document clearly", "Need for transfer to psychiatry ward?", "Medicolegal issues: POCSO, JJB, testamentary capacity", ], "⑧ FORMULATION & COMMUNICATION", [ "Provisional Dx (DSM/ICD) + probable aetiology", "Causal/treatment interaction with medical illness", "Biopsychosocial background relevant to management", "Immediate risk & ward transfer decision", "Written notes + DIRECT telephonic communication to team", "Transparent explanation to patient & family (no discrepancy)", "Follow-up: within 1 week if pharmacotherapy started", "Post-discharge: psychiatry OPD follow-up plan", ], lhc=HDR2, rhc=HDR )) story.append(Spacer(1, 2*mm)) story.append(HRFlowable(width="100%", thickness=0.8, color=HDR, spaceAfter=1.5*mm)) # Bottom banner: The 3Cs + setting-specific reminders banner_data = [[ Paragraph('3 Cs of C-L Psychiatry: Conceptualisation • Communication • Collaboration', ParagraphStyle( 'banner', parent=styles['Normal'], fontSize=7.5, fontName='Helvetica-Bold', textColor=WHITE, alignment=TA_CENTER)), Paragraph('Setting reminders: ER → MHTS triage first | ICU → rule out NCSE | Wards → serial MSE | Board → organicity + malingering', ParagraphStyle( 'banner2', parent=styles['Normal'], fontSize=7, fontName='Helvetica', textColor=WHITE, alignment=TA_CENTER)), ]] banner_table = Table(banner_data, colWidths=[90*mm, 96*mm]) banner_table.setStyle(TableStyle([ ('BACKGROUND', (0,0), (0,0), HDR), ('BACKGROUND', (1,0), (1,0), HDR2), ('TOPPADDING', (0,0), (-1,-1), 4), ('BOTTOMPADDING', (0,0), (-1,-1), 4), ('LEFTPADDING', (0,0), (-1,-1), 5), ('RIGHTPADDING', (0,0), (-1,-1), 5), ])) story.append(banner_table) story.append(Spacer(1, 1*mm)) story.append(Paragraph( "Ghosal & Ray, Indian J Psychiatry 2022 | van Niekerk et al. J Acad CLP 2022 | Carpenter et al. Acad Emerg Med 2024 | Quinlivan et al. BMC Psychiatry 2025 | ACLP How-To Guides 2024–25", note_style)) doc.build(story) print("PDF created:", output_path) PYEOF

Your one-page exam checklist is ready:

CL Assessment Checklist

PDF Document · PDF

Here is what is on it - all fitted to a single A4 page in 8 colour-coded sections:

Section	Content
① Preparatory Phase	Chart review, MHTS triage, referral focus, family
② 5 Core Questions	Syndrome / Why now / Primary vs. secondary / Risks / Management
③ Psychiatric Interview	Sequence from open narrative → vegetative → internalising → externalising → cognitive → substance
④ MSE	Consciousness first → catatonia → speech → affect → psychosis → suicidality → cognition → insight
⑤ Aetiological Differential	6-point framework + organicity red flags
⑥ Screening Tools	By domain - delirium, depression, anxiety, cognition, suicide, substance, somatic
⑦ Risk Assessment	SI/NSSI, hopelessness triad, harm to others, capacity, medicolegal
⑧ Formulation & Communication	DSM/ICD Dx, aetiology, written notes, telephonic liaison, follow-up plan

Bottom banner: The 3 Cs + setting-specific reminders (ER / ICU / Wards / Boards)

2.1 Principles and objectives • Ensure immediate medical and psychiatric safety. • Clarify the reason, urgency and specific clinical question for referral. • Differentiate primary psychiatric illness from medical, neurological, medication-induced and substance-related syndromes. • Identify delirium and cognitive impairment early. • Assess suicide/self-harm, violence, vulnerability, treatment refusal and risk to medical care. • Assess decision-making capacity for the specific decision when relevant. • Understand the patient's baseline cognition, personality and functioning. • Develop a biopsychosocial and etiological formulation. • Communicate an actionable plan to the treating team and arrange reassessment. 2.1 Principles and objectives of assessment • Ensure medical and psychiatric safety. • Clarify the reason and urgency of referral. • Establish the nature, severity, chronology and functional impact of symptoms. • Differentiate primary psychiatric illness from medical, neurological, pharmacological and substance-related causes. • Identify delirium and cognitive impairment. • Assess suicide/self-harm, violence, vulnerability and risk to medical treatment. • Assess decision-making capacity when relevant. • Obtain collateral information and establish premorbid functioning. • Develop a biopsychosocial and etiological formulation. • Communicate an actionable plan to the treating team and arrange reassessment/follow-up. 2.1 Principles and Objectives of Psychiatric Assessment The assessment of psychiatric disorders in medically ill patients differs fundamentally from routine psychiatric evaluation because the psychiatrist must determine why psychiatric symptoms have developed, whether they are reversible, and how they influence ongoing medical care. A systematic, hypothesis-driven approach minimizes diagnostic errors, facilitates communication with the treating team, and ensures timely recognition of psychiatric disorders that adversely affect medical outcomes. Principles of Assessment The following principles should guide every psychiatric assessment in the medical setting: 1. Think Organic First : Every new-onset behavioural, emotional, or cognitive disturbance should be considered secondary to a medical or neurological disorder until proven otherwise. Acute confusion, altered consciousness, hallucinations, or personality change warrant immediate evaluation for delirium, metabolic disturbances, drug toxicity, infection, or structural brain disease before a primary psychiatric diagnosis is entertained. (7) 2. Ensure Medical Stability : Stabilization of airway, breathing, circulation, and other life-threatening medical conditions always takes precedence over detailed psychiatric assessment. Psychiatric evaluation should never delay emergency medical treatment. (1) 3. Adopt a Biopsychosocial Approach : Psychiatric symptoms should always be interpreted within the broader context of the patient's physical illness, personality, coping mechanisms, family environment, cultural background, and social circumstances. Biological disease, psychological responses, and social determinants frequently interact to produce complex clinical presentations. (4) 4. Establish the Chronology : Determining the temporal relationship between psychiatric symptoms, medical illness, surgery, medication exposure, and substance use is often the most valuable diagnostic tool in Consultation-Liaison Psychiatry. The sequence of events frequently distinguishes primary psychiatric disorders from secondary neuropsychiatric syndromes. (7) "Timeline is often the diagnosis." 5. Review Medications Systematically : Drug-induced psychiatric disorders are common in hospitalized patients. Every assessment should include a careful review of prescribed medications, recent dose changes, recently discontinued drugs, over-the-counter preparations, herbal remedies, and potential drug interactions. (7) 6. Obtain Collateral Information: Information obtained from family members, caregivers, nursing staff, and treating physicians is often indispensable, particularly in patients with delirium, dementia, psychosis, impaired insight, or altered consciousness. Collateral history helps establish the patient's baseline cognitive function, personality, and behaviour, thereby improving diagnostic accuracy. (7) 7. Perform Serial Assessments :Psychiatric symptoms in medically ill patients frequently fluctuate over time. Repeated bedside assessments allow recognition of evolving delirium, medication-related adverse effects, emerging neurological deficits, and changes in decision-making capacity. (7) 8. Work Collaboratively. Effective assessment requires continuous communication with the multidisciplinary team to ensure that psychiatric recommendations are integrated into the overall medical management plan. (4) Objectives of Psychiatric Assessment A comprehensive psychiatric assessment aims to: • Establish the nature, severity, chronology, and functional impact of psychiatric symptoms. • Differentiate primary psychiatric disorders from psychiatric manifestations of general medical conditions. • Identify medication-induced and substance-related psychiatric syndromes. • Detect delirium and other neurocognitive disorders at an early stage. • Assess cognitive function, decision-making capacity, suicide risk, and behavioural disturbances. • Identify psychosocial stressors, coping mechanisms, caregiver burden, and available support systems. • Recognize factors influencing adherence to medical treatment and rehabilitation. • Formulate an integrated biopsychosocial diagnosis and individualized management plan in collaboration with the treating team. (1,7) Figure 2.1. Principles of Psychiatric Assessment in Consultation-Liaison Psychiatry Psychiatric Symptoms │ ▼ Is the patient medically stable? │ ┌─────────────────┴─────────────────┐ │ │ No Yes │ │ Stabilize medical illness Comprehensive Assessment │ │ └─────────────────┬─────────────────┘ ▼ Think Organic • Review Medications ▼ Biopsychosocial Clinical Assessment ▼ Integrated Diagnostic Formulation ▼ Collaborative Multidisciplinary Management go through this and create one rich output for my medal exam which can be produced in 5mins.

Here is the gold-medal output - tight enough to write in 5 minutes, rich enough to stand out:

2.1 Principles and Objectives of Psychiatric Assessment in C-L Psychiatry

Assessment of psychiatric disorders in medically ill patients differs fundamentally from routine psychiatric evaluation. The psychiatrist must determine why psychiatric symptoms have developed, whether they are reversible, and how they influence ongoing medical care. A systematic, hypothesis-driven approach minimises diagnostic errors, ensures timely recognition of treatable conditions, and facilitates effective communication with the treating team.¹˒⁷

Principles of Assessment

8 guiding principles - remember with mnemonic: "TO ABC SWC"

#	Principle	Key Point
1	Think Organic First	Every new-onset behavioural, emotional, or cognitive disturbance is secondary to medical/neurological cause until proven otherwise. Confusion, altered consciousness, hallucinations → rule out delirium, metabolic disturbance, drug toxicity, infection, structural brain disease first.⁷
2	Organic stability (Medical Stability)	Airway, breathing, circulation first. Psychiatric assessment never delays emergency medical treatment.¹
3	Adopt Biopsychosocial Approach	Biological disease + psychological response + social determinants interact to produce complex presentations. Never interpret symptoms in isolation.⁴
4	Build a Timeline (Chronology)	Temporal relationship between symptoms, medical illness, surgery, medications, and substances is often the single most valuable diagnostic tool. "Timeline is often the diagnosis."⁷
5	Check Medications Systematically	Drug-induced psychiatric disorders are common in hospital. Review prescribed drugs, recent dose changes, stopped drugs, OTC preparations, herbal remedies, interactions.⁷
6	Seek Collateral Information	Family, nurses, treating physicians - indispensable in delirium, dementia, psychosis, impaired insight. Establishes baseline cognition, personality, behaviour.⁷
7	Watch Serially (Repeat Assessments)	Psychiatric symptoms fluctuate. Serial assessments detect evolving delirium, drug effects, neurological deficits, and capacity changes.⁷
8	Collaborate with MDT	Psychiatric recommendations must be integrated into the overall medical management plan through continuous communication.⁴

Objectives of Assessment

A comprehensive CL psychiatric assessment aims to:

Establish the nature, severity, chronology, and functional impact of psychiatric symptoms
Differentiate primary psychiatric disorder from medical, neurological, pharmacological, and substance-related causes
Detect delirium and neurocognitive disorders early
Assess cognitive function and decision-making capacity
Assess suicide risk, self-harm, violence, vulnerability, and risk to medical treatment
Identify psychosocial stressors, coping mechanisms, caregiver burden, and support systems
Recognise factors affecting adherence to medical treatment and rehabilitation
Formulate an integrated biopsychosocial diagnosis and individualised management plan
Communicate an actionable plan to the treating team and arrange reassessment/follow-up¹˒⁷

Decision Pathway (Figure 2.1)

         Psychiatric Symptoms in a Medically Ill Patient
                            │
                            ▼
               Is the patient medically stable?
                ┌───────────┴───────────┐
               NO                      YES
                │                       │
     Stabilise medical illness    Comprehensive Assessment
                └───────────┬───────────┘
                            ▼
              Think Organic  •  Review Medications
                            ▼
           Biopsychosocial Clinical Assessment
           (History + MSE + Collateral + Serial)
                            ▼
             Integrated Diagnostic Formulation
                            ▼
        Collaborative Multidisciplinary Management

Gold-Medal Exam Summary (write this in 5 minutes)

CL psychiatric assessment is hypothesis-driven and iterative. Eight core principles guide it - "TO ABC SWC" (Think organic, Medical stability, Biopsychosocial, Chronology, Check medications, Seek collateral, Watch serially, Collaborate with MDT). The objectives span syndromic identification, aetiological differentiation, risk assessment, capacity assessment, and a collaborative biopsychosocial formulation. The first decision is always: is the patient stable? If yes - assess comprehensively. If no - stabilise first, assess second. A CL psychiatrist maintains both a psychiatric formulation and a medical differential simultaneously, never closing either prematurely.

Exam write-up structure: Introduction (2 lines) → Principles as numbered table with 1-line key point each → Objectives as numbered list → Decision pathway as a 5-step flow → closing summary sentence. This covers everything an examiner looks for and takes under 5 minutes.

too big for 5mins

Here is the real 5-minute version:

2.1 Principles & Objectives of CL Psychiatric Assessment

Assessment in medically ill inpatients is hypothesis-driven and iterative - the goal is not just diagnosis, but determining why symptoms arose, whether reversible, and how they affect medical care.¹˒⁷

8 Principles — mnemonic: "TO ABC SWC"

	Principle	One-liner
T	Think organic first	All new behavioural/cognitive symptoms = medical until proven otherwise
O	stablise (medical stability)	ABC before psychiatry - never delay emergency care
A	Adopt biopsychosocial approach	Biology + psychology + social context always interact
B	Build a timeline	"Timeline is often the diagnosis"
C	Check medications	Prescribed, stopped, OTC, herbal, interactions
S	Seek collateral	Family/nurses essential in delirium, dementia, psychosis
W	Watch serially	Symptoms fluctuate - repeat assessments are mandatory
C	Collaborate with MDT	Integrate psychiatric plan into medical management

Objectives (8 - write as a list)

Nature, severity, chronology and functional impact of symptoms
Differentiate primary psychiatric vs. medical/drug/substance cause
Detect delirium and neurocognitive disorders early
Assess capacity, suicide risk, violence, vulnerability
Identify psychosocial stressors and support systems
Assess treatment adherence factors
Formulate integrated biopsychosocial diagnosis
Communicate actionable plan + arrange reassessment¹˒⁷

Flow (draw this - 10 seconds)

Symptoms → Stable? → NO: Stabilise first
                   → YES: Think organic + Check meds
                              ↓
                   Biopsychosocial Assessment
                              ↓
                   Formulation → MDT Plan

Assessment of a medically ill patient is an integrated, iterative process that begins with review of the medical context and referral question, ensures physiological and psychiatric safety, establishes the chronology of symptoms and baseline functioning, obtains collateral information, performs a CL-adapted mental status and cognitive examination, actively identifies delirium and other reversible medical, neurological, pharmacological and substance-related causes, assesses risk and decision-making capacity, incorporates psychosocial and special-population factors, and culminates in a biopsychosocial formulation. The psychiatrist then communicates an actionable plan to the medical team and reassesses as the patient's condition evolves. creat flow chart

Running Command

mkdir -p /tmp/workspace/cl-checklist && python3 << 'PYEOF' import matplotlib matplotlib.use('Agg') import matplotlib.pyplot as plt import matplotlib.patches as mpatches from matplotlib.patches import FancyBboxPatch, FancyArrowPatch import matplotlib.patheffects as pe fig, ax = plt.subplots(1, 1, figsize=(10, 18)) ax.set_xlim(0, 10) ax.set_ylim(0, 18) ax.axis('off') fig.patch.set_facecolor('#f7fafd') # ── Colour palette ────────────────────────────────────────────────── C_DARK = '#1a3a5c' # dark navy C_MID = '#2e6da4' # medium blue C_LIGHT = '#5ba3d9' # light blue C_GREEN = '#217a3c' # dark green C_LGREEN = '#2ecc71' # light green accent C_RED = '#c0392b' # red C_ORANGE = '#d68910' # amber C_GREY = '#ecf4fb' # very light blue-grey bg C_WHITE = '#ffffff' C_TEXT = '#1a1a1a' def box(ax, x, y, w, h, label, sublabel=None, facecolor=C_MID, textcolor=C_WHITE, fontsize=9.5, subfontsize=7.8, radius=0.25, bold=True, shadow=True): fancy = FancyBboxPatch((x - w/2, y - h/2), w, h, boxstyle=f"round,pad=0.05,rounding_size={radius}", facecolor=facecolor, edgecolor=C_DARK, linewidth=0.9, zorder=3) if shadow: shadow_box = FancyBboxPatch((x - w/2 + 0.05, y - h/2 - 0.06), w, h, boxstyle=f"round,pad=0.05,rounding_size={radius}", facecolor='#bbbbbb', edgecolor='none', linewidth=0, alpha=0.35, zorder=2) ax.add_patch(shadow_box) ax.add_patch(fancy) fw = 'bold' if bold else 'normal' if sublabel: ax.text(x, y + 0.13, label, ha='center', va='center', fontsize=fontsize, color=textcolor, fontweight=fw, zorder=4) ax.text(x, y - 0.17, sublabel, ha='center', va='center', fontsize=subfontsize, color=textcolor, fontstyle='italic', zorder=4) else: ax.text(x, y, label, ha='center', va='center', fontsize=fontsize, color=textcolor, fontweight=fw, zorder=4) def arrow(ax, x, y1, y2, color=C_DARK, lw=1.6): ax.annotate('', xy=(x, y2 + 0.02), xytext=(x, y1 - 0.02), arrowprops=dict(arrowstyle='->', color=color, lw=lw, connectionstyle='arc3,rad=0.0'), zorder=5) def side_note(ax, x, y, text, color=C_GREY, tcolor=C_DARK, fontsize=7.2, w=2.6, h=0.42): fancy = FancyBboxPatch((x, y - h/2), w, h, boxstyle="round,pad=0.04,rounding_size=0.12", facecolor=color, edgecolor=C_MID, linewidth=0.6, zorder=3) ax.add_patch(fancy) ax.text(x + w/2, y, text, ha='center', va='center', fontsize=fontsize, color=tcolor, zorder=4) def dashed_line(ax, x1, y1, x2, y2, color=C_MID): ax.plot([x1, x2], [y1, y2], '--', color=color, lw=0.9, alpha=0.7, zorder=2) # ── TITLE ──────────────────────────────────────────────────────────── ax.text(5, 17.65, 'C-L PSYCHIATRY: SYSTEMATIC ASSESSMENT FLOWCHART', ha='center', va='center', fontsize=11.5, fontweight='bold', color=C_DARK, zorder=6) ax.text(5, 17.3, 'Assessment of the Medically Ill Inpatient — Integrated, Iterative Process', ha='center', va='center', fontsize=8, color='#444444', fontstyle='italic', zorder=6) ax.plot([0.5, 9.5], [17.1, 17.1], color=C_DARK, lw=1.5) # ── STEP 1: Referral ───────────────────────────────────────────────── y1 = 16.5 box(ax, 5, y1, 8.5, 0.58, '① REFERRAL RECEIVED', 'Review medical context • Clarify clinical question • Determine urgency (MHTS triage)', facecolor=C_DARK, fontsize=10) side_note(ax, 7.25, y1, 'MHTS: Red/Orange/Yellow/Green/Blue', C_GREY) arrow(ax, 5, y1 - 0.29, 15.75) # ── STEP 2: Medical Stability ───────────────────────────────────────── y2 = 15.65 box(ax, 5, y2, 8.5, 0.58, '② IS THE PATIENT MEDICALLY STABLE?', 'Airway • Breathing • Circulation • Acute life-threatening conditions', facecolor=C_RED, fontsize=10) # No branch ax.annotate('', xy=(1.5, 14.85), xytext=(1.5, y2 - 0.29), arrowprops=dict(arrowstyle='->', color=C_RED, lw=1.5), zorder=5) side_note(ax, 0.1, 14.6, ' NO → Stabilise first\n Psychiatry waits', color='#fdecea', tcolor=C_RED, fontsize=7, w=2.7, h=0.5) # Yes arrow arrow(ax, 5, y2 - 0.29, y2 - 0.71) ax.text(5.2, y2 - 0.5, 'YES', fontsize=8, color=C_GREEN, fontweight='bold') # ── STEP 3: Preparatory Phase ───────────────────────────────────────── y3 = 14.7 box(ax, 5, y3, 8.5, 0.58, '③ PREPARATORY PHASE (before entering ward)', 'Chart review • Medications • Nursing obs • Collateral arranged • Prior psychiatric Hx', facecolor=C_MID, fontsize=10) arrow(ax, 5, y3 - 0.29, y3 - 0.71) # ── STEP 4: Establish Chronology ────────────────────────────────────── y4 = 13.75 box(ax, 5, y4, 8.5, 0.58, '④ ESTABLISH CHRONOLOGY & BASELINE', 'Timeline of symptoms vs. illness / surgery / medications / substances • Premorbid functioning', facecolor=C_MID, fontsize=10) side_note(ax, 7.25, y4, '"Timeline is often the diagnosis"', color='#fff8e1', tcolor=C_ORANGE, fontsize=7.5) arrow(ax, 5, y4 - 0.29, y4 - 0.71) # ── STEP 5: History + Collateral ───────────────────────────────────── y5 = 12.8 box(ax, 5, y5, 8.5, 0.58, '⑤ HISTORY & COLLATERAL INFORMATION', 'Patient interview • Family / carers • Nursing staff • Treating team', facecolor=C_MID, fontsize=10) arrow(ax, 5, y5 - 0.29, y5 - 0.71) # ── STEP 6: MSE + Cognitive ─────────────────────────────────────────── y6 = 11.85 box(ax, 5, y6, 8.5, 0.68, '⑥ CL-ADAPTED MSE + COGNITIVE EXAMINATION', 'Consciousness→Attention→Orientation (delirium first) • Catatonia • Speech/Thought\n' 'Affect • Psychosis • Suicidality • Cognition: MMSE / MoCA / CAM / CAM-ICU', facecolor=C_DARK, fontsize=10, h=0.72) arrow(ax, 5, y6 - 0.36, y6 - 0.76) # ── STEP 7: Think Organic ───────────────────────────────────────────── y7 = 10.8 box(ax, 5, y7, 8.5, 0.72, '⑦ THINK ORGANIC — ACTIVE AETIOLOGICAL SEARCH', 'Delirium • Metabolic / infective / autoimmune • Structural brain disease\n' 'Drug-induced (anticholinergics / steroids / ART / antitubercular) • Substance intoxication / withdrawal', facecolor='#7d1a1a', textcolor=C_WHITE, fontsize=10, h=0.76) side_note(ax, 7.25, y7, 'NEECHAM / CAM-ICU / 4AT\nfor delirium screening', color='#fdecea', tcolor=C_RED, fontsize=7, h=0.48) arrow(ax, 5, y7 - 0.38, y7 - 0.78) # ── STEP 8: Risk Assessment ─────────────────────────────────────────── y8 = 9.7 box(ax, 5, y8, 8.5, 0.68, '⑧ RISK & CAPACITY ASSESSMENT', 'Suicide / self-harm (C-SSRS) • Violence / aggression • Vulnerability\n' 'Decision-making capacity (specific decision) • Risk to medical treatment / adherence', facecolor=C_RED, fontsize=10, h=0.72) arrow(ax, 5, y8 - 0.36, y8 - 0.76) # ── STEP 9: Psychosocial + Special Pops ────────────────────────────── y9 = 8.65 box(ax, 5, y9, 8.5, 0.68, '⑨ PSYCHOSOCIAL & SPECIAL POPULATION FACTORS', 'Stressors • Coping • Caregiver burden • Social support • Premorbid personality\n' 'Cultural / religious factors • Elderly / children / perinatal / transplant / POCSO', facecolor=C_MID, fontsize=10, h=0.72) arrow(ax, 5, y9 - 0.36, y9 - 0.76) # ── STEP 10: Formulation ────────────────────────────────────────────── y10 = 7.55 box(ax, 5, y10, 8.5, 0.72, '⑩ BIOPSYCHOSOCIAL FORMULATION', 'Syndrome • Aetiology (primary / secondary / combined) • Drug interactions\n' 'DSM / ICD provisional Dx • Risk summary • Predisposing / Precipitating / Perpetuating / Protective', facecolor=C_GREEN, fontsize=10, h=0.76) arrow(ax, 5, y10 - 0.38, y10 - 0.78) # ── STEP 11: Communication ──────────────────────────────────────────── y11 = 6.4 box(ax, 5, y11, 8.5, 0.68, '⑪ COMMUNICATE ACTIONABLE PLAN TO TREATING TEAM', 'Written notes + Direct telephonic communication • No discrepancy with medical team\n' 'Patient & family explanation • Prescribe / recommend / refer as needed', facecolor=C_DARK, fontsize=10, h=0.72) arrow(ax, 5, y11 - 0.36, y11 - 0.76) # ── STEP 12: Reassessment Loop ──────────────────────────────────────── y12 = 5.3 box(ax, 5, y12, 8.5, 0.68, '⑫ REASSESS AS CONDITION EVOLVES', 'Serial MSE • Physiology / cognition / treatment changed → repeat assessment\n' 'Follow-up within 1 week if pharmacotherapy started • Post-discharge OPD plan', facecolor=C_MID, fontsize=10, h=0.72) # Feedback loop arrow ax.annotate('', xy=(9.15, y6), xytext=(9.15, y12), arrowprops=dict(arrowstyle='->', color=C_LIGHT, lw=1.4, connectionstyle='arc3,rad=0.0'), zorder=5) ax.plot([9.15, 9.4], [y12, y12], color=C_LIGHT, lw=1.4) ax.plot([9.15, 9.4], [y6, y6], color=C_LIGHT, lw=1.4) ax.text(9.55, (y6 + y12)/2, 'Iterative\nLoop', ha='center', va='center', fontsize=7, color=C_LIGHT, rotation=90, fontstyle='italic') # ── LEGEND / FOOTER ─────────────────────────────────────────────────── ax.add_patch(FancyBboxPatch((0.3, 0.35), 9.4, 0.9, boxstyle="round,pad=0.05", facecolor='#eaf2fb', edgecolor=C_DARK, linewidth=0.8, zorder=3)) legend_items = [ (C_DARK, 'Entry / Communication / Formulation'), (C_MID, 'Assessment Steps'), (C_RED, 'Safety / Risk / Organic'), (C_GREEN,'Synthesis / Formulation'), ] for i, (col, label) in enumerate(legend_items): lx = 0.6 + i * 2.35 ax.add_patch(mpatches.Rectangle((lx, 0.72), 0.28, 0.22, facecolor=col, edgecolor='none', zorder=4)) ax.text(lx + 0.35, 0.83, label, fontsize=6.8, va='center', color=C_TEXT, zorder=4) ax.text(5, 0.47, 'Ghosal & Ray, Indian J Psychiatry 2022 | van Niekerk et al. J Acad CLP 2022 | ' 'Carpenter et al. Acad Emerg Med 2024 | ACLP How-To Guides 2024–25', ha='center', va='center', fontsize=6.2, color='#555555', fontstyle='italic', zorder=4) plt.tight_layout(pad=0.3) plt.savefig('/tmp/workspace/cl-checklist/CL_Assessment_Flowchart.png', dpi=180, bbox_inches='tight', facecolor='#f7fafd') plt.close() print("Done") PYEOF

Running Command

python3 << 'PYEOF' import matplotlib matplotlib.use('Agg') import matplotlib.pyplot as plt import matplotlib.patches as mpatches from matplotlib.patches import FancyBboxPatch import warnings warnings.filterwarnings('ignore') fig, ax = plt.subplots(1, 1, figsize=(10, 19)) ax.set_xlim(0, 10) ax.set_ylim(0, 19) ax.axis('off') fig.patch.set_facecolor('#f7fafd') C_DARK = '#1a3a5c' C_MID = '#2e6da4' C_LIGHT = '#5ba3d9' C_GREEN = '#1e6b3c' C_RED = '#b03030' C_ORANGE = '#c87800' C_GREY = '#ecf4fb' C_WHITE = '#ffffff' C_TEXT = '#1a1a1a' def draw_box(ax, cx, cy, w, bh, line1, line2=None, fc=C_MID, tc=C_WHITE, fs=9.5, fs2=7.6, bold=True): shadow = FancyBboxPatch((cx-w/2+0.05, cy-bh/2-0.06), w, bh, boxstyle="round,pad=0.05,rounding_size=0.2", facecolor='#aaaaaa', edgecolor='none', alpha=0.3, zorder=2) ax.add_patch(shadow) rect = FancyBboxPatch((cx-w/2, cy-bh/2), w, bh, boxstyle="round,pad=0.05,rounding_size=0.2", facecolor=fc, edgecolor=C_DARK, linewidth=0.9, zorder=3) ax.add_patch(rect) fw = 'bold' if bold else 'normal' if line2: ax.text(cx, cy+0.14, line1, ha='center', va='center', fontsize=fs, color=tc, fontweight=fw, zorder=4) ax.text(cx, cy-0.17, line2, ha='center', va='center', fontsize=fs2, color=tc, fontstyle='italic', zorder=4) else: ax.text(cx, cy, line1, ha='center', va='center', fontsize=fs, color=tc, fontweight=fw, zorder=4) def draw_arrow(ax, cx, y_from, y_to, col=C_DARK): ax.annotate('', xy=(cx, y_to+0.03), xytext=(cx, y_from-0.03), arrowprops=dict(arrowstyle='->', color=col, lw=1.6), zorder=5) def side_tag(ax, x, cy, text, fc='#fff8e1', tc=C_ORANGE, w=2.55, bh=0.38): r = FancyBboxPatch((x, cy-bh/2), w, bh, boxstyle="round,pad=0.04,rounding_size=0.1", facecolor=fc, edgecolor=C_MID, linewidth=0.6, zorder=3) ax.add_patch(r) ax.text(x+w/2, cy, text, ha='center', va='center', fontsize=6.9, color=tc, zorder=4) # ── TITLE ──────────────────────────────────────────────────────────── ax.text(5, 18.6, 'C-L PSYCHIATRY: SYSTEMATIC ASSESSMENT FLOWCHART', ha='center', fontsize=12, fontweight='bold', color=C_DARK, zorder=6) ax.text(5, 18.25, 'Integrated, Iterative Assessment of the Medically Ill Inpatient', ha='center', fontsize=8.2, color='#555', fontstyle='italic', zorder=6) ax.plot([0.4, 9.6], [18.05, 18.05], color=C_DARK, lw=1.5) # Steps: (cy, bh, line1, line2, fc, tc, side_tag_text, side_tag_fc, side_tag_tc) steps = [ # cy, bh, line1, line2, fc, side_text, sfc, stc (17.45, 0.56, '① REFERRAL RECEIVED', 'Review medical context • Clarify clinical question • Determine urgency', C_DARK, 'MHTS: Red / Orange / Yellow\nGreen / Blue triage', '#eaf2fb', C_MID), (16.55, 0.56, '② MEDICAL STABILITY CHECK', 'Airway • Breathing • Circulation • Life-threatening conditions first', C_RED, 'NO → Stabilise first\nPsychiatry waits', '#fdecea', C_RED), (15.65, 0.56, '③ PREPARATORY PHASE', 'Chart + medications + nursing obs • Collateral arranged • Prior psychiatric Hx', C_MID, 'Psychotropic Hx\nDrug interactions', C_GREY, C_MID), (14.75, 0.56, '④ ESTABLISH CHRONOLOGY & BASELINE', 'Timeline: symptoms vs illness / surgery / medications / substances • Premorbid functioning', C_MID, '"Timeline is often\nthe diagnosis"', '#fff8e1', C_ORANGE), (13.85, 0.56, '⑤ HISTORY & COLLATERAL', 'Patient interview • Family / carers • Nursing staff • Treating team', C_MID, 'Indispensable in\ndelirium / dementia', C_GREY, C_MID), (12.88, 0.68, '⑥ CL-ADAPTED MSE + COGNITIVE EXAM', 'Consciousness→Attention→Orientation (delirium first) • Catatonia • Speech / Thought / Affect\n' ' Psychosis • Suicidality • Cognition: MMSE / MoCA / CAM / CAM-ICU', C_DARK, 'NEECHAM / 4AT\nCAM-ICU / RASS', '#eaf2fb', C_MID), (11.88, 0.68, '⑦ THINK ORGANIC — AETIOLOGICAL SEARCH', 'Delirium • Metabolic / infective / autoimmune / structural brain disease\n' ' Drug-induced (steroids / anticholinergics / ART) • Intoxication / withdrawal', C_RED, 'Red flags: late-onset\natypical / fluctuating', '#fdecea', C_RED), (10.90, 0.68, '⑧ RISK & CAPACITY ASSESSMENT', 'Suicide / self-harm (C-SSRS) • Violence • Vulnerability • Risk to medical Rx\n' ' Decision-making capacity — assess for the specific decision', C_RED, 'C-SSRS • SSI\nHopelessness triad', '#fdecea', C_RED), (9.93, 0.68, '⑨ PSYCHOSOCIAL & SPECIAL POPULATIONS', 'Stressors • Coping • Caregiver burden • Social support • Personality\n' ' Cultural / religious • Elderly / children / perinatal / transplant / POCSO', C_MID, 'PSS / CD-RISC\nfor stress-resilience', C_GREY, C_MID), (8.93, 0.72, '⑩ BIOPSYCHOSOCIAL FORMULATION', 'Syndrome • Aetiology (primary / secondary / combined) • Drug interactions\n' ' DSM/ICD provisional Dx • Risk summary • 4 Ps: Predisposing / Precipitating\n' ' / Perpetuating / Protective', C_GREEN, '4 Ps formulation\nBiopsychosocial Dx', '#e8f5ee', C_GREEN), (7.88, 0.56, '⑪ COMMUNICATE ACTIONABLE PLAN', 'Written notes + Direct telephonic liaison • Patient & family explanation • No discrepancy', C_DARK, 'Prescribe / refer\nas needed', C_GREY, C_MID), (6.98, 0.56, '⑫ REASSESS AS CONDITION EVOLVES', 'Serial MSE • Physiology / cognition / Rx changed → repeat • Follow-up: ≤1 wk if pharmacotherapy', C_MID, 'Iterative loop\n→ back to Step ⑥', '#eaf2fb', C_LIGHT), ] prev_cy = None prev_bh = None for idx, s in enumerate(steps): cy, bh, l1, l2, fc, st, sfc, stc = s draw_box(ax, 5, cy, 8.5, bh, l1, l2, fc=fc) side_tag(ax, 7.3, cy, st, fc=sfc, tc=stc) if prev_cy is not None: draw_arrow(ax, 5, prev_cy - prev_bh/2, cy + bh/2) prev_cy = cy prev_bh = bh # YES label after step 2 ax.text(5.2, 16.05, 'YES ▼', fontsize=8, color=C_GREEN, fontweight='bold') # Iterative loop arc on left side loop_top = 12.88 + 0.34 loop_bot = 6.98 - 0.28 ax.annotate('', xy=(0.85, loop_top), xytext=(0.85, loop_bot), arrowprops=dict(arrowstyle='->', color=C_LIGHT, lw=1.5, connectionstyle='arc3,rad=0.0'), zorder=5) ax.plot([0.55, 0.85], [loop_bot, loop_bot], color=C_LIGHT, lw=1.4) ax.plot([0.55, 0.85], [loop_top, loop_top], color=C_LIGHT, lw=1.4) ax.text(0.28, (loop_top+loop_bot)/2, 'I\nT\nE\nR\nA\nT\nI\nV\nE', ha='center', va='center', fontsize=6.5, color=C_LIGHT, fontweight='bold', fontstyle='italic') # ── FOOTER LEGEND ───────────────────────────────────────────────────── ax.add_patch(FancyBboxPatch((0.3, 0.25), 9.4, 0.95, boxstyle="round,pad=0.05", facecolor='#eaf2fb', edgecolor=C_DARK, linewidth=0.8, zorder=3)) legend_items = [ (C_DARK, 'Entry / Output / Communication'), (C_MID, 'Assessment Steps'), (C_RED, 'Safety / Risk / Organic Search'), (C_GREEN, 'Formulation / Synthesis'), ] for i, (col, label) in enumerate(legend_items): lx = 0.55 + i * 2.35 ax.add_patch(mpatches.Rectangle((lx, 0.76), 0.28, 0.22, facecolor=col, edgecolor='none', zorder=4)) ax.text(lx+0.36, 0.87, label, fontsize=7, va='center', color=C_TEXT, zorder=4) ax.text(5, 0.44, 'Ghosal & Ray, Indian J Psychiatry 2022 | van Niekerk et al. J Acad CLP 2022 | ' 'Carpenter et al. Acad Emerg Med 2024 | Quinlivan et al. BMC Psychiatry 2025', ha='center', fontsize=6.3, color='#666', fontstyle='italic', zorder=4) plt.tight_layout(pad=0.2) out = '/tmp/workspace/cl-checklist/CL_Assessment_Flowchart.png' plt.savefig(out, dpi=180, bbox_inches='tight', facecolor='#f7fafd') plt.close() print("Saved:", out) PYEOF

Here is your flowchart:

CL Assessment Flowchart

Image · PNG

What the flowchart contains:

Colour	Meaning
Navy	Entry point, communication, output
Blue	Core assessment steps
Red	Safety stops - medical stability, organic search, risk/capacity
Green	Biopsychosocial formulation (synthesis)

Key features:

12 sequential steps exactly matching the paragraph you provided
Side tags on every step with the tool, mnemonic, or key phrase (MHTS, 4AT, C-SSRS, 4 Ps, "Timeline is the diagnosis")
YES branch visible after the medical stability check
Iterative loop arrow on the left side - Step ⑫ feeds back to Step ⑥ whenever condition changes
Colour-coded legend and citations at the bottom

word document

Reading File

Running Command

python3 << 'PYEOF' from docx import Document from docx.shared import Pt, Inches, RGBColor, Cm from docx.enum.text import WD_ALIGN_PARAGRAPH from docx.enum.table import WD_TABLE_ALIGNMENT, WD_ALIGN_VERTICAL from docx.oxml.ns import qn from docx.oxml import OxmlElement import copy doc = Document() # ── Page margins ───────────────────────────────────────────────────── section = doc.sections[0] section.page_width = Cm(21) section.page_height = Cm(29.7) section.top_margin = Cm(1.5) section.bottom_margin = Cm(1.5) section.left_margin = Cm(2) section.right_margin = Cm(2) # ── Default font ───────────────────────────────────────────────────── normal = doc.styles['Normal'] normal.font.name = 'Calibri' normal.font.size = Pt(10.5) # ── Helpers ────────────────────────────────────────────────────────── NAVY = RGBColor(0x1a, 0x3a, 0x5c) BLUE = RGBColor(0x2e, 0x6d, 0xa4) RED = RGBColor(0xb0, 0x30, 0x30) GREEN = RGBColor(0x1e, 0x6b, 0x3c) WHITE = RGBColor(0xFF, 0xFF, 0xFF) LGREY = RGBColor(0xea, 0xf2, 0xfb) LRED = RGBColor(0xfd, 0xec, 0xea) LGREEN = RGBColor(0xe8, 0xf5, 0xee) LBLUE = RGBColor(0xea, 0xf2, 0xfb) def set_cell_bg(cell, rgb: RGBColor): tc = cell._tc tcPr = tc.get_or_add_tcPr() shd = OxmlElement('w:shd') hex_color = f'{rgb.red:02X}{rgb.green:02X}{rgb.blue:02X}' shd.set(qn('w:val'), 'clear') shd.set(qn('w:color'), 'auto') shd.set(qn('w:fill'), hex_color) tcPr.append(shd) def cell_para(cell, text, bold=False, italic=False, color=None, size=10, align=WD_ALIGN_PARAGRAPH.LEFT, space_before=0, space_after=0): p = cell.paragraphs[0] if cell.paragraphs else cell.add_paragraph() p.alignment = align p.paragraph_format.space_before = Pt(space_before) p.paragraph_format.space_after = Pt(space_after) p.paragraph_format.left_indent = Pt(0) run = p.add_run(text) run.bold = bold run.italic = italic run.font.size = Pt(size) run.font.name = 'Calibri' if color: run.font.color.rgb = color return p def add_para(text, bold=False, italic=False, color=None, size=11, align=WD_ALIGN_PARAGRAPH.LEFT, space_before=4, space_after=2): p = doc.add_paragraph() p.alignment = align p.paragraph_format.space_before = Pt(space_before) p.paragraph_format.space_after = Pt(space_after) run = p.add_run(text) run.bold = bold run.italic = italic run.font.size = Pt(size) run.font.name = 'Calibri' if color: run.font.color.rgb = color return p def add_rule(color=NAVY, thickness=12): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(2) p.paragraph_format.space_after = Pt(2) pPr = p._p.get_or_add_pPr() pBdr = OxmlElement('w:pBdr') bottom = OxmlElement('w:bottom') hex_color = f'{color.red:02X}{color.green:02X}{color.blue:02X}' bottom.set(qn('w:val'), 'single') bottom.set(qn('w:sz'), str(thickness)) bottom.set(qn('w:space'), '1') bottom.set(qn('w:color'), hex_color) pBdr.append(bottom) pPr.append(pBdr) # ═══════════════════════════════════════════════════════════════════ # TITLE BLOCK # ═══════════════════════════════════════════════════════════════════ t = doc.add_table(rows=1, cols=1) t.alignment = WD_TABLE_ALIGNMENT.CENTER t.style = 'Table Grid' tc = t.rows[0].cells[0] set_cell_bg(tc, NAVY) tc.width = Cm(17) p = tc.paragraphs[0] p.alignment = WD_ALIGN_PARAGRAPH.CENTER p.paragraph_format.space_before = Pt(6) p.paragraph_format.space_after = Pt(2) r = p.add_run('C-L PSYCHIATRY: SYSTEMATIC ASSESSMENT FLOWCHART') r.bold = True; r.font.size = Pt(14); r.font.name = 'Calibri'; r.font.color.rgb = WHITE p2 = tc.add_paragraph() p2.alignment = WD_ALIGN_PARAGRAPH.CENTER p2.paragraph_format.space_after = Pt(6) r2 = p2.add_run('Integrated, Iterative Assessment of the Medically Ill Inpatient') r2.italic = True; r2.font.size = Pt(10); r2.font.name = 'Calibri'; r2.font.color.rgb = RGBColor(0xcc, 0xdd, 0xee) doc.add_paragraph().paragraph_format.space_after = Pt(2) # ═══════════════════════════════════════════════════════════════════ # FLOWCHART TABLE (step | description | side-tag) # ═══════════════════════════════════════════════════════════════════ steps = [ ('① REFERRAL RECEIVED', NAVY, WHITE, 'Review medical context • Clarify clinical question • Determine urgency (MHTS triage)', 'MHTS: Red / Orange\nYellow / Green / Blue', LBLUE, BLUE), ('② MEDICAL STABILITY CHECK', RED, WHITE, 'Airway • Breathing • Circulation • Acute life-threatening conditions first\n' 'NO → Stabilise first. Psychiatric assessment NEVER delays emergency medical treatment.', 'NO → Stabilise first\nPsychiatry waits', LRED, RED), ('③ PREPARATORY PHASE', BLUE, WHITE, 'Chart review • Medications (prescribed, stopped, OTC, herbal, interactions)\n' 'Nursing observations • Collateral arranged • Prior psychiatric history', 'Psychotropic Hx\nDrug interactions', LBLUE, BLUE), ('④ ESTABLISH CHRONOLOGY & BASELINE', BLUE, WHITE, 'Timeline: symptoms vs illness / surgery / medications / substances\n' 'Premorbid cognitive functioning • Personality • Baseline behaviour\n' '"Timeline is often the diagnosis."', '"Timeline is often\nthe diagnosis"', RGBColor(0xff,0xf8,0xe1), RGBColor(0xc8,0x78,0x00)), ('⑤ HISTORY & COLLATERAL', BLUE, WHITE, 'Patient interview (open narrative → vegetative → internalising → externalising)\n' 'Family / carers • Nursing staff • Treating team\n' 'Indispensable in delirium, dementia, psychosis, impaired insight', 'Memory-LAPSE (elderly)\nSubstance Hx: AUDIT', LBLUE, BLUE), ('⑥ CL-ADAPTED MSE + COGNITIVE EXAM', NAVY, WHITE, 'Consciousness → Attention → Orientation (delirium first)\n' 'Catatonia • Speech / Thought • Affect • Psychosis • Suicidality\n' 'Cognitive screening: MMSE / MoCA / CAM / CAM-ICU / RASS', 'NEECHAM / 4AT\nCAM-ICU / RASS', LBLUE, BLUE), ('⑦ THINK ORGANIC — AETIOLOGICAL SEARCH', RED, WHITE, 'Delirium • Metabolic / infective / autoimmune / structural brain disease\n' 'Drug-induced: steroids, anticholinergics, ART, antitubercular, fluoroquinolones\n' 'Substance intoxication / withdrawal • NCSE (non-convulsive status epilepticus)', 'Red flags: late-onset\natypical / fluctuating\nneurological signs', LRED, RED), ('⑧ RISK & CAPACITY ASSESSMENT', RED, WHITE, 'Suicide / self-harm: intent, plan, lethality, previous attempts (C-SSRS / SSI)\n' 'Violence / aggression • Vulnerability • Risk to medical treatment / adherence\n' 'Decision-making capacity — assess for the SPECIFIC decision in question', 'C-SSRS (free)\nHopelessness triad\nBPRS for agitation', LRED, RED), ('⑨ PSYCHOSOCIAL & SPECIAL POPULATIONS', BLUE, WHITE, 'Stressors • Coping mechanisms • Caregiver burden • Social support\n' 'Premorbid personality • Cultural / religious factors\n' 'Elderly (GDS, MoCA) • Children (CPMS) • Perinatal • Transplant • POCSO', 'PSS / CD-RISC\nfor stress-resilience', LBLUE, BLUE), ('⑩ BIOPSYCHOSOCIAL FORMULATION', GREEN, WHITE, 'Syndrome identified • Aetiology (primary / secondary / combined)\n' 'Drug-psychiatric interactions • DSM / ICD provisional diagnosis\n' '4 Ps: Predisposing • Precipitating • Perpetuating • Protective\n' 'Maintain psychiatric formulation AND medical differential simultaneously', '4 Ps formulation\nBiopsychosocial Dx\nDSM / ICD', LGREEN, GREEN), ('⑪ COMMUNICATE ACTIONABLE PLAN', NAVY, WHITE, 'Written notes in case record • Direct telephonic communication to treating consultant\n' 'No discrepancy between medical team and psychiatric team messages\n' 'Transparent explanation to patient and family • Prescribe / recommend / refer', 'Prescribe / refer\nas needed', LBLUE, BLUE), ('⑫ REASSESS AS CONDITION EVOLVES', BLUE, WHITE, 'Serial MSE — physiology / cognition / treatment changed → REPEAT assessment\n' 'Follow-up within 1 week if pharmacotherapy started\n' 'Post-discharge psychiatry OPD plan • Iterative loop → back to Step ⑥', 'Iterative loop\n→ repeat from ⑥\nwhenever Rx changes', LBLUE, BLUE), ] for i, (step_title, step_fc, step_tc, desc, tag_text, tag_fc, tag_tc) in enumerate(steps): tbl = doc.add_table(rows=1, cols=2) tbl.alignment = WD_TABLE_ALIGNMENT.CENTER tbl.style = 'Table Grid' # Column widths for j, w in enumerate([Cm(12.5), Cm(4.3)]): for cell in tbl.columns[j].cells: cell.width = w left = tbl.rows[0].cells[0] right = tbl.rows[0].cells[1] # Left: step header + description set_cell_bg(left, step_fc) lp1 = left.paragraphs[0] lp1.alignment = WD_ALIGN_PARAGRAPH.LEFT lp1.paragraph_format.space_before = Pt(3) lp1.paragraph_format.space_after = Pt(1) r1 = lp1.add_run(step_title) r1.bold = True; r1.font.size = Pt(10.5); r1.font.name = 'Calibri' r1.font.color.rgb = step_tc lp2 = left.add_paragraph() lp2.alignment = WD_ALIGN_PARAGRAPH.LEFT lp2.paragraph_format.space_before = Pt(1) lp2.paragraph_format.space_after = Pt(4) r2 = lp2.add_run(desc) r2.italic = True; r2.font.size = Pt(9); r2.font.name = 'Calibri' r2.font.color.rgb = step_tc # Right: side tag set_cell_bg(right, tag_fc) rp = right.paragraphs[0] rp.alignment = WD_ALIGN_PARAGRAPH.CENTER rp.paragraph_format.space_before = Pt(6) rp.paragraph_format.space_after = Pt(6) rt = rp.add_run(tag_text) rt.font.size = Pt(8.5); rt.font.name = 'Calibri'; rt.bold = True rt.font.color.rgb = tag_tc # Arrow row between steps if i < len(steps) - 1: arr_tbl = doc.add_table(rows=1, cols=1) arr_tbl.alignment = WD_TABLE_ALIGNMENT.CENTER arr_cell = arr_tbl.rows[0].cells[0] arr_cell.width = Cm(16.8) ap = arr_cell.paragraphs[0] ap.alignment = WD_ALIGN_PARAGRAPH.CENTER ap.paragraph_format.space_before = Pt(0) ap.paragraph_format.space_after = Pt(0) ar = ap.add_run('▼') ar.font.size = Pt(9); ar.font.name = 'Calibri' ar.font.color.rgb = NAVY # ── YES label note after step 2 ────────────────────────────────────── # (embedded in description already; add a small italic note) # ═══════════════════════════════════════════════════════════════════ # ITERATIVE LOOP NOTE # ═══════════════════════════════════════════════════════════════════ doc.add_paragraph().paragraph_format.space_after = Pt(3) loop_tbl = doc.add_table(rows=1, cols=1) loop_tbl.style = 'Table Grid' loop_tbl.alignment = WD_TABLE_ALIGNMENT.CENTER lc = loop_tbl.rows[0].cells[0] set_cell_bg(lc, LBLUE) lp = lc.paragraphs[0] lp.alignment = WD_ALIGN_PARAGRAPH.CENTER lp.paragraph_format.space_before = Pt(4) lp.paragraph_format.space_after = Pt(4) lr = lp.add_run( '↺ ITERATIVE LOOP: When physiology, cognition or treatment changes → ' 'return to Step ⑥ (MSE) and reassess. Serial assessment is mandatory.') lr.bold = True; lr.font.size = Pt(9.5); lr.font.name = 'Calibri' lr.font.color.rgb = NAVY # ═══════════════════════════════════════════════════════════════════ # LEGEND # ═══════════════════════════════════════════════════════════════════ doc.add_paragraph().paragraph_format.space_after = Pt(2) add_rule() leg_tbl = doc.add_table(rows=1, cols=4) leg_tbl.alignment = WD_TABLE_ALIGNMENT.CENTER leg_tbl.style = 'Table Grid' legend = [ (NAVY, WHITE, 'Entry / Output /\nCommunication'), (BLUE, WHITE, 'Assessment\nSteps'), (RED, WHITE, 'Safety / Risk /\nOrganic Search'), (GREEN, WHITE, 'Formulation /\nSynthesis'), ] for j, (fc, tc, label) in enumerate(legend): lc = leg_tbl.rows[0].cells[j] set_cell_bg(lc, fc) lp = lc.paragraphs[0] lp.alignment = WD_ALIGN_PARAGRAPH.CENTER lp.paragraph_format.space_before = Pt(4) lp.paragraph_format.space_after = Pt(4) lr = lp.add_run(label) lr.bold = True; lr.font.size = Pt(8.5); lr.font.name = 'Calibri' lr.font.color.rgb = tc # ═══════════════════════════════════════════════════════════════════ # CITATIONS # ═══════════════════════════════════════════════════════════════════ add_para( 'References: Ghosal & Ray, Indian J Psychiatry 2022 | ' 'van Niekerk et al. J Acad CLP 2022 | ' 'Carpenter et al. Acad Emerg Med 2024 | ' 'Quinlivan et al. BMC Psychiatry 2025 | ACLP How-To Guides 2024–25', italic=True, color=RGBColor(0x55,0x55,0x55), size=8, align=WD_ALIGN_PARAGRAPH.CENTER, space_before=4, space_after=2) # ── Save ────────────────────────────────────────────────────────────── out = '/tmp/workspace/cl-checklist/CL_Assessment_Flowchart.docx' doc.save(out) print('Saved:', out) PYEOF

Running Command

python3 << 'PYEOF' from docx import Document from docx.shared import Pt, Cm, RGBColor from docx.enum.text import WD_ALIGN_PARAGRAPH from docx.enum.table import WD_TABLE_ALIGNMENT from docx.oxml.ns import qn from docx.oxml import OxmlElement doc = Document() section = doc.sections[0] section.page_width = Cm(21) section.page_height = Cm(29.7) section.top_margin = Cm(1.5) section.bottom_margin = Cm(1.5) section.left_margin = Cm(2) section.right_margin = Cm(2) normal = doc.styles['Normal'] normal.font.name = 'Calibri' normal.font.size = Pt(10.5) # ── Use hex strings directly ────────────────────────────────────────── def set_cell_bg(cell, hex_color: str): """hex_color like '1a3a5c' (no #)""" tc = cell._tc tcPr = tc.get_or_add_tcPr() # remove existing shd if any for existing in tcPr.findall(qn('w:shd')): tcPr.remove(existing) shd = OxmlElement('w:shd') shd.set(qn('w:val'), 'clear') shd.set(qn('w:color'), 'auto') shd.set(qn('w:fill'), hex_color.upper()) tcPr.append(shd) def rgb(r, g, b): return RGBColor(r, g, b) # Colour map as hex strings NAVY_H = '1A3A5C'; NAVY_R = rgb(0x1a, 0x3a, 0x5c) BLUE_H = '2E6DA4'; BLUE_R = rgb(0x2e, 0x6d, 0xa4) RED_H = 'B03030'; RED_R = rgb(0xb0, 0x30, 0x30) GREEN_H = '1E6B3C'; GREEN_R = rgb(0x1e, 0x6b, 0x3c) WHITE_H = 'FFFFFF'; WHITE_R = rgb(0xff, 0xff, 0xff) LBLUE_H = 'EAF2FB'; LBLUE_R = rgb(0xea, 0xf2, 0xfb) LRED_H = 'FDECEA'; LRED_R = rgb(0xfd, 0xec, 0xea) LGREEN_H = 'E8F5EE'; LGREEN_R = rgb(0xe8, 0xf5, 0xee) AMBER_H = 'FFF8E1'; AMBER_R = rgb(0xff, 0xf8, 0xe1) AMBERT_R = rgb(0xc8, 0x78, 0x00) GREY_R = rgb(0x55, 0x55, 0x55) # ── TITLE block ──────────────────────────────────────────────────── t = doc.add_table(rows=1, cols=1) t.alignment = WD_TABLE_ALIGNMENT.CENTER t.style = 'Table Grid' tc = t.rows[0].cells[0] tc.width = Cm(17) set_cell_bg(tc, NAVY_H) p1 = tc.paragraphs[0] p1.alignment = WD_ALIGN_PARAGRAPH.CENTER p1.paragraph_format.space_before = Pt(6) p1.paragraph_format.space_after = Pt(1) r1 = p1.add_run('C-L PSYCHIATRY: SYSTEMATIC ASSESSMENT FLOWCHART') r1.bold = True; r1.font.size = Pt(13.5) r1.font.name = 'Calibri'; r1.font.color.rgb = WHITE_R p2 = tc.add_paragraph() p2.alignment = WD_ALIGN_PARAGRAPH.CENTER p2.paragraph_format.space_after = Pt(5) r2 = p2.add_run('Integrated, Iterative Assessment of the Medically Ill Inpatient') r2.italic = True; r2.font.size = Pt(9.5) r2.font.name = 'Calibri'; r2.font.color.rgb = rgb(0xcc, 0xdd, 0xee) doc.add_paragraph().paragraph_format.space_after = Pt(1) # ── Steps data ──────────────────────────────────────────────────── # (title, title_bg_hex, title_text_rgb, desc, tag, tag_bg_hex, tag_text_rgb) steps = [ ('① REFERRAL RECEIVED', NAVY_H, WHITE_R, 'Review medical context • Clarify clinical question • Determine urgency (MHTS triage)', 'MHTS: Red / Orange\nYellow / Green / Blue', LBLUE_H, BLUE_R), ('② MEDICAL STABILITY CHECK', RED_H, WHITE_R, 'Airway • Breathing • Circulation • Life-threatening conditions FIRST\n' 'NO → Stabilise first. Psychiatric assessment NEVER delays emergency medical treatment.', 'NO → Stabilise\nfirst. Psychiatry\nwaits', LRED_H, RED_R), ('③ PREPARATORY PHASE', BLUE_H, WHITE_R, 'Chart review • Medications (prescribed / stopped / OTC / herbal / interactions)\n' 'Nursing observations • Collateral arranged • Prior psychiatric history', 'Psychotropic Hx\nDrug interactions', LBLUE_H, BLUE_R), ('④ ESTABLISH CHRONOLOGY & BASELINE', BLUE_H, WHITE_R, 'Timeline: symptoms vs illness / surgery / medications / substances\n' 'Premorbid cognition • Personality • Baseline behaviour\n' '"Timeline is often the diagnosis."', '"Timeline is often\nthe diagnosis"', AMBER_H, AMBERT_R), ('⑤ HISTORY & COLLATERAL', BLUE_H, WHITE_R, 'Patient interview (open narrative → vegetative → internalising → externalising)\n' 'Family / carers • Nursing staff • Treating team\n' 'Indispensable in delirium, dementia, psychosis, impaired insight', 'Memory-LAPSE\n(elderly)\nAUDIT for alcohol', LBLUE_H, BLUE_R), ('⑥ CL-ADAPTED MSE + COGNITIVE EXAM', NAVY_H, WHITE_R, 'Consciousness → Attention → Orientation (delirium first) • Catatonia\n' 'Speech / Thought • Affect • Psychosis • Suicidality\n' 'Cognitive screening: MMSE / MoCA / CAM / CAM-ICU / RASS', 'NEECHAM / 4AT\nCAM-ICU / RASS', LBLUE_H, BLUE_R), ('⑦ THINK ORGANIC — AETIOLOGICAL SEARCH', RED_H, WHITE_R, 'Delirium • Metabolic / infective / autoimmune / structural brain disease\n' 'Drug-induced: steroids / anticholinergics / ART / antitubercular / fluoroquinolones\n' 'Substance intoxication / withdrawal • NCSE (non-convulsive status epilepticus)', 'Red flags: late-onset\natypical / fluctuating\nneurological signs', LRED_H, RED_R), ('⑧ RISK & CAPACITY ASSESSMENT', RED_H, WHITE_R, 'Suicide / self-harm: intent, plan, lethality, previous attempts (C-SSRS / SSI)\n' 'Violence / aggression • Vulnerability • Risk to medical treatment / adherence\n' 'Decision-making capacity — assess for the SPECIFIC decision in question', 'C-SSRS (free)\nHopelessness triad\nBPRS for agitation', LRED_H, RED_R), ('⑨ PSYCHOSOCIAL & SPECIAL POPULATIONS', BLUE_H, WHITE_R, 'Stressors • Coping mechanisms • Caregiver burden • Social support • Personality\n' 'Cultural / religious factors\n' 'Elderly (GDS / MoCA) • Children (CPMS) • Perinatal • Transplant • POCSO / JJB', 'PSS / CD-RISC for\nstress & resilience', LBLUE_H, BLUE_R), ('⑩ BIOPSYCHOSOCIAL FORMULATION', GREEN_H, WHITE_R, 'Syndrome • Aetiology (primary / secondary / combined) • Drug-psychiatric interactions\n' 'DSM / ICD provisional diagnosis • Risk summary\n' '4 Ps: Predisposing • Precipitating • Perpetuating • Protective', '4 Ps formulation\nDSM / ICD Dx\nBiopsychosocial', LGREEN_H, GREEN_R), ('⑪ COMMUNICATE ACTIONABLE PLAN', NAVY_H, WHITE_R, 'Written notes • Direct telephonic communication to treating consultant\n' 'No discrepancy between medical team and psychiatric team messages\n' 'Transparent explanation to patient and family • Prescribe / recommend / refer', 'Prescribe / refer\nno discrepancy\nwith medical team', LBLUE_H, BLUE_R), ('⑫ REASSESS AS CONDITION EVOLVES', BLUE_H, WHITE_R, 'Serial MSE • Physiology / cognition / treatment changed → REPEAT assessment\n' 'Follow-up within 1 week if pharmacotherapy started\n' 'Post-discharge psychiatry OPD plan • Iterative loop → back to Step ⑥', 'Iterative loop\n→ repeat from ⑥\nwhen Rx changes', LBLUE_H, BLUE_R), ] for i, (title, t_bg, t_tc, desc, tag, tag_bg, tag_tc) in enumerate(steps): tbl = doc.add_table(rows=1, cols=2) tbl.alignment = WD_TABLE_ALIGNMENT.CENTER tbl.style = 'Table Grid' # widths tbl.columns[0].width = Cm(12.5) tbl.columns[1].width = Cm(4.3) for cell in tbl.columns[0].cells: cell.width = Cm(12.5) for cell in tbl.columns[1].cells: cell.width = Cm(4.3) left = tbl.rows[0].cells[0] right = tbl.rows[0].cells[1] set_cell_bg(left, t_bg) p_title = left.paragraphs[0] p_title.alignment = WD_ALIGN_PARAGRAPH.LEFT p_title.paragraph_format.space_before = Pt(3) p_title.paragraph_format.space_after = Pt(1) rt = p_title.add_run(title) rt.bold = True; rt.font.size = Pt(10.5) rt.font.name = 'Calibri'; rt.font.color.rgb = t_tc p_desc = left.add_paragraph() p_desc.alignment = WD_ALIGN_PARAGRAPH.LEFT p_desc.paragraph_format.space_before = Pt(1) p_desc.paragraph_format.space_after = Pt(4) rd = p_desc.add_run(desc) rd.italic = True; rd.font.size = Pt(9) rd.font.name = 'Calibri'; rd.font.color.rgb = t_tc set_cell_bg(right, tag_bg) p_tag = right.paragraphs[0] p_tag.alignment = WD_ALIGN_PARAGRAPH.CENTER p_tag.paragraph_format.space_before = Pt(8) p_tag.paragraph_format.space_after = Pt(8) rg = p_tag.add_run(tag) rg.bold = True; rg.font.size = Pt(8.5) rg.font.name = 'Calibri'; rg.font.color.rgb = tag_tc # Arrow between steps if i < len(steps) - 1: at = doc.add_table(rows=1, cols=1) at.alignment = WD_TABLE_ALIGNMENT.CENTER at.style = 'Table Grid' ac = at.rows[0].cells[0] ac.width = Cm(16.8) set_cell_bg(ac, 'F7FAFD') ap = ac.paragraphs[0] ap.alignment = WD_ALIGN_PARAGRAPH.CENTER ap.paragraph_format.space_before = Pt(0) ap.paragraph_format.space_after = Pt(0) ar = ap.add_run('▼') ar.font.size = Pt(9); ar.font.name = 'Calibri' ar.font.color.rgb = NAVY_R # ── Iterative loop note ─────────────────────────────────────────────── doc.add_paragraph().paragraph_format.space_after = Pt(3) lt = doc.add_table(rows=1, cols=1) lt.style = 'Table Grid' lt.alignment = WD_TABLE_ALIGNMENT.CENTER lc = lt.rows[0].cells[0] set_cell_bg(lc, LBLUE_H) lp = lc.paragraphs[0] lp.alignment = WD_ALIGN_PARAGRAPH.CENTER lp.paragraph_format.space_before = Pt(5) lp.paragraph_format.space_after = Pt(5) lr = lp.add_run( '↺ ITERATIVE LOOP: When physiology, cognition or treatment changes' ' → return to Step ⑥ (MSE) and reassess. Serial assessment is mandatory.') lr.bold = True; lr.font.size = Pt(9.5) lr.font.name = 'Calibri'; lr.font.color.rgb = NAVY_R # ── Legend ──────────────────────────────────────────────────────────── doc.add_paragraph().paragraph_format.space_after = Pt(2) legend_tbl = doc.add_table(rows=1, cols=4) legend_tbl.alignment = WD_TABLE_ALIGNMENT.CENTER legend_tbl.style = 'Table Grid' leg = [ (NAVY_H, WHITE_R, 'Entry / Output\nCommunication'), (BLUE_H, WHITE_R, 'Assessment\nSteps'), (RED_H, WHITE_R, 'Safety / Risk\nOrganic Search'), (GREEN_H, WHITE_R, 'Formulation\nSynthesis'), ] for j, (bg, tc, label) in enumerate(leg): lc2 = legend_tbl.rows[0].cells[j] set_cell_bg(lc2, bg) p = lc2.paragraphs[0] p.alignment = WD_ALIGN_PARAGRAPH.CENTER p.paragraph_format.space_before = Pt(4) p.paragraph_format.space_after = Pt(4) r = p.add_run(label) r.bold = True; r.font.size = Pt(8.5) r.font.name = 'Calibri'; r.font.color.rgb = tc # ── Citations ───────────────────────────────────────────────────────── cp = doc.add_paragraph() cp.alignment = WD_ALIGN_PARAGRAPH.CENTER cp.paragraph_format.space_before = Pt(5) cp.paragraph_format.space_after = Pt(2) cr = cp.add_run( 'References: Ghosal & Ray, Indian J Psychiatry 2022 | van Niekerk et al. J Acad CLP 2022 | ' 'Carpenter et al. Acad Emerg Med 2024 | Quinlivan et al. BMC Psychiatry 2025 | ACLP How-To Guides 2024–25') cr.italic = True; cr.font.size = Pt(7.8) cr.font.name = 'Calibri'; cr.font.color.rgb = GREY_R out = '/tmp/workspace/cl-checklist/CL_Assessment_Flowchart.docx' doc.save(out) print('Saved:', out) PYEOF

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CL Assessment Flowchart

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What is inside the document:

Title block in navy with subtitle
12 colour-coded step rows, each with:
- Left cell: step number + bold title + italic description (full detail)
- Right cell: side tag with key tools / mnemonics / warnings
▼ arrows between every step
Iterative loop banner at the bottom in blue
Colour legend (Navy / Blue / Red / Green)
Citations in small italic text at the foot

Colour	Meaning
Navy	Entry, Output, Communication (Steps 1, 6, 11)
Blue	Core assessment steps
Red	Safety stops - medical stability, organic search, risk/capacity
Green	Biopsychosocial formulation

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