Running the initial evaluation

You conduct Sofia's evaluation in the live room, and a side panel keeps you on the rails of a complete report. That panel carries the evaluation spine — every section a defensible psychiatric evaluation needs, in order, each showing a readiness state so you can see at a glance what's done and what's still thin.

The spine runs from presenting illness through history, the symptom inventory, psychiatric and substance history, the MSEmental status examination — the structured observation of appearance, mood, thought, cognition, and insight at the time of the visit., impressions, causation, GAF, functional limitations, treatment recommendations, and prognosis. You capture pre-injury and initial GAF here — for Sofia, a pre-injury 85 against an initial 52, the gap that quantifies her loss of function.

1. 1Open Sofia's case at the evaluation slot; the live room opens with the §9785 spine in the side panel.
2. 2Work top-down — presenting illness, history, symptom inventory, psych and substance history.
3. 3Complete the MSE section from what you observe in the room.
4. 4Record your impressions, then the causation section, then both GAF timepoints (pre-injury and initial).
5. 5Document functional limitations, treatment recommendations, and prognosis as the conversation reaches them.
6. 6Use Flag moment to mark any clinically important point with its timestamp for later review.

Document as the conversation happens rather than reconstructing it afterward — the spine is there precisely so you don't have to hold the structure in your head. When Sofia describes the pediatric fatality she couldn't save, that's a Flag moment: one tap pins the point with its timestamp, and you can return to it when you write impressions or causation.