How to Gather Current Treatment Provider Information
This is Part 4 in our series on Past Psychiatric History.
Read Part 3: Psychiatric Hospitalization History for the previous component.
Most patients receive care within a network of providers managing different aspects of their health. Identifying this treatment team is essential for coordination, preventing medication errors, avoiding conflicting recommendations, obtaining collateral information, and planning discharge. Your task is to determine who is involved, how long they’ve been engaged, and when they were last seen.
Learning Objectives
After reading this section, you should be able to:
• Identify chart sources that reveal a patient’s active provider network.
• Conduct interview questions that clarify provider roles, frequency, and recent changes.
• Recognize warning signs of fragmented or low-intensity care.
• Document provider continuity and gaps relevant to risk formulation and discharge planning.
Start With Chart Review
Before interviewing the patient, review available documentation:
- Recent clinical notes – Look for references to outside providers (therapists, psychiatrists, PCPs)
- Medication lists – Prescriber names indicate active relationships with providers
- Referral records – Recent referrals show newly established care
- Release of information forms – Who has the patient authorized for communication?
- Appointment records – Scheduled or completed visits with external providers
Document provider names, specialties, and contact information when available. This creates your baseline before speaking with the patient.
💡 Clinical Pearl: Check medication prescriber names carefully. If three different psychiatrists prescribed the current medication regimen, this suggests provider changes and potential continuity issues worth exploring.
Interview the Patient
After chart review, interview the patient to confirm, clarify, and add providers not documented in the system.
Opening Questions
- “Who are you currently seeing for mental health treatment?”
- “Do you have a therapist? A psychiatrist? What are their names?”
- “Are you involved with any programs like day treatment or intensive outpatient?”
- “Who is your primary care doctor?”
Confirm and Clarify from the Chart:
- “I see Dr. [Name] prescribed your medication. Are you still seeing them?”
Identifying the Full Treatment Team
Cast a wide net. The current care team may include:
Mental health specialists:
- Psychiatrist or psychopharmacologist
- Therapist, psychologist, or counselor
- Psychiatric nurse practitioner or physician assistant
- Case manager or care coordinator
Specialized programs:
- Day treatment or partial hospitalization program
- Intensive outpatient program
- Residential program or group home staff
- Substance use treatment programs
Other medical providers:
- Primary care physician
- Neurologist (for seizure disorders, dementia, movement disorders)
- Pain management specialist
Gathering Detail on Each Provider
For each provider identified, ask:
Contact and identification:
- “What’s their full name?”
- “Where is their office located?”
- “Do you have their phone number?”
Nature of involvement:
- “What do they help you with – medications, therapy, both?”
- “How long have you been seeing them?”
- “How often do you meet – weekly, monthly?”
Recent contact:
- “When was your last appointment with them?”
- “When is your next appointment scheduled?”
- “Have you missed any appointments recently?”
Recent changes:
- “Has anything changed with this provider recently – like seeing them less often or stopping?”
- “Have you switched providers or stopped seeing anyone in the past few months?”
🚩 PITFALL: Assuming Stability Without Checking for Changes
A patient reports seeing a therapist and psychiatrist regularly for “years” – sounds like strong, stable engagement.
What you missed: Detailed questioning reveals that until 3 months ago, the patient saw the therapist weekly and psychiatrist monthly. The treatment team recently reduced frequency to every 3 months due to perceived stability. Since this change, the patient has been hospitalized 3 times.
The lesson: The reduction in care intensity directly correlates with clinical deterioration. Always ask not just WHO is involved, but HOW LONG, HOW OFTEN, and WHETHER ANYTHING HAS CHANGED RECENTLY. Stable provider relationships don’t guarantee stable intensity of services.
Assessing Engagement Through Appointment Timing
The timing of recent and upcoming appointments reveals critical information about engagement, access, and continuity:
Last appointment timing shows:
- Recent contact suggests active engagement
- Long gaps may indicate disengagement, access barriers, or provider availability issues
- Missed appointments may indicate symptom severity or ambivalence
Next appointment timing shows:
- Appointments scheduled within days/weeks suggest good continuity
- Long gaps before next visit may require interim care (IOP, partial hospitalization, bridge appointments)
- No scheduled appointment suggests discharge planning needs
What to Document
Documentation should balance completeness with practicality.
| Level | Items | Example | Use When |
| Minimal | Provider/Schedule | “Current providers: Dr. Smith (psychiatrist, monthly), Jane Doe LCSW (therapist, weekly), Dr. Jones (PCP)” | Stable outpatient care |
| Standard | Above + Recent contact | “Psychiatrist: Dr. Smith at [Practice name], seen monthly for medication management (last visit 2 weeks ago, next appointment in 3 weeks)” “Therapist: Jane Doe LCSW, weekly therapy for 2 years (last session 1 week ago)” “PCP: Dr. Jones (last visit 6 months ago for annual physical)” | Uncertain Stability |
| Detailed | Above + More details | “Psychiatrist: Dr. Smith, monthly visits for 3 years. Last appointment 4 months ago – patient reports ‘couldn’t get in sooner’ and has been without medication refills for 6 weeks. Next available appointment is 2 months out.” | Recent changes |
When providers have changed:
- “Previous psychiatrist: Dr. Adams (2020-2023, stopped due to insurance change). Current psychiatrist: Dr. Smith (since January 2024, seen 3 times)”
The key is capturing provider continuity, recent contact, and any changes or gaps that explain current presentation.
Why This Information Matters
The treatment provider network reveals several things:
Engagement capacity: Long-standing relationships suggest ability to engage. Frequent provider changes may indicate personality dynamics, geographic instability, or treatment dissatisfaction.
Care coordination needs: Multiple prescribers require medication reconciliation. Fragmented care increases risk of conflicting advice or duplicated services.
Discharge planning: Knowing who will continue care after your evaluation determines whether recommendations can be implemented. A patient without outpatient providers needs different discharge planning than one with weekly therapy scheduled.
Collateral information sources: Current providers can offer longitudinal perspectives on symptoms, treatment response, and baseline functioning that transform your understanding of the case.
This foundation prepares you for the next component: understanding what actually happens in therapy and what psychotherapeutic approaches have been tried.
By mapping the treatment network, you’re identifying both the patient’s safety net and its weak points – information that directly shapes your risk formulation and discharge plan.
Next in this series: Part 5: Understanding Support Systems – Types of therapy, duration, frequency, and therapeutic benefit.
Previous post: Part 3: Psychiatric Hospitalization History – Gathering admission patterns and frequency.
